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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/14515-0.txt b/14515-0.txt new file mode 100644 index 0000000..5026d99 --- /dev/null +++ b/14515-0.txt @@ -0,0 +1,6012 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 14515 *** + +THE NERVOUS CHILD + + + + +PUBLISHED BY THE JOINT COMMITTEE OF +HENRY FROWDE, HODDER & STOUGHTON +17 WARWICK SQUARE, LONDON, E.C. 4 + + + + +THE + +NERVOUS CHILD + + +BY + +HECTOR CHARLES CAMERON +M.A., M.D.(CANTAB.), F.R.C.P.(LOND.) +PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF +THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL + + + "RESPECT the child. Be not too much his parent. Trespass not on + his solitude."--EMERSON. + + +LONDON +HENRY FROWDE HODDER & STOUGHTON +OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C. +1920 + + + + +_First Edition_ 1919 +_Second Impression_ 1930 + + + + +PRINTED IN GREAT BRITAIN +BY MORRISON & GIBB LTD., EDINBURGH + + + + +PREFACE + + +To-day on all sides we hear of the extreme importance of Preventive +Medicine and the great future which lies before us in this aspect of +our work. If so, it follows that the study of infancy and childhood +must rise into corresponding prominence. More and more a considerable +part of the Profession must busy itself in nurseries and in schools, +seeking to apply there the teachings of Psychology, Physiology, +Heredity, and Hygiene. To work of this kind, in some of its aspects, +this book may serve as an introduction. It deals with the influences +which mould the mentality of the child and shape his conduct. Extreme +susceptibility to these influences is the mark of the nervous child. + +I have to thank the Editors of _The Practitioner_ and of _The Child_, +respectively, for permission to reprint the chapters which deal with +"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I +should also like to offer thanks for helpful suggestions. + +H.C.C. + +_March_ 1919. + + + + +CONTENTS + +CHAP. PAGE + + I. DOCTORS, MOTHERS, AND CHILDREN 1 + + II. OBSERVATIONS IN THE NURSERY 16 + + III. WANT OF APPETITE AND INDIGESTION 50 + + IV. WANT OF SLEEP 64 + + V. SOME OTHER SIGNS OF NERVOUSNESS 73 + + VI. ENURESIS 89 + + VII. TOYS, BOOKS, AND AMUSEMENTS 96 + +VIII. NERVOUSNESS IN EARLY INFANCY 104 + + IX. MANAGEMENT IN LATER CHILDHOOD 117 + + X. NERVOUSNESS IN OLDER CHILDREN 131 + + XI. NERVOUSNESS AND PHYSIQUE 145 + + XII. THE NERVOUS CHILD IN SICKNESS 160 + +XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS 169 + + XIV. THE NERVOUS CHILD AND SCHOOL 182 + + INDEX 191 + + + + +THE NERVOUS CHILD + +CHAPTER I + +DOCTORS, MOTHERS, AND CHILDREN + + +There is an old fairy story concerning a pea which a princess once +slept upon--a little offending pea, a minute disturbance, a trifling +departure from the normal which grew to the proportions of intolerable +suffering because of the too sensitive and undisciplined nervous +system of Her Royal Highness. The story, I think, does not tell us +much else concerning the princess. It does not tell us, for instance, +if she was an only child, the sole preoccupation of her parents and +nurses, surrounded by the most anxious care, reared with some +difficulty because of her extraordinary "delicacy," suffering from a +variety of illnesses which somehow always seemed to puzzle the +doctors, though some of the symptoms--the vomiting, for example, and +the high temperature--were very severe and persistent. Nor does it +tell us if later in life, but before the suffering from the pea arose, +she had been taken to consult two famous doctors, one of whom had +removed the vermiform appendix, while the other a little later had +performed an operation for "adhesions." At any rate, the story with +these later additions, which are at least in keeping with what we know +of her history, would serve to indicate the importance which attaches +to the early training of childhood. Among the children even of the +well-to-do often enough the hygiene of the mind is overlooked, and +faulty management produces restlessness, instability, and +hyper-sensitiveness, which pass insensibly into neuropathy in adult +life. + +To prevent so distressing a result is our aim in the training of +children. No doubt the matter concerns in the first place parents and +nurses, school masters and mistresses, as well as medical men. Yet +because of the certainty that physical disturbances of one sort or +another will follow upon nervous unrest, it will seldom happen that +medical advice will not be sought sooner or later; and if the +physician is to intervene with success, he must be prepared with +knowledge of many sorts. He must be prepared to make a thorough and +complete physical examination, sufficient to exclude the presence of +organic disease. If no organic disease is found, he must explore the +whole environment of the child, and seek to determine whether the +exciting cause is to be found in the reaction of the child to some +form of faulty management. + +For example, a child of two or three years of age may be brought to +the doctor with the complaint that defæcation is painful, and that +there has existed for some time a most distressing constipation which +has resisted a large number of purgatives of increasing strength. +Whenever the child is placed upon the stool, his crying at once +begins, and no attempts to soothe or console him have been successful. +It is not sufficient for the doctor in such a case to make an +examination which convinces him that there is no fissure at the anus +and no fistula or thrombosed pile, and to confine himself to saying +that he can find nothing the matter. The crying and refusal to go to +stool will continue after the visit as before, and the mother will be +apt to conclude that her doctor, though she has the greatest +confidence in him for the ailments of grown-up persons, is unskilled +in, or at least not interested in, the diseases of little children. +If, on the other hand, the doctor pursues his inquiries into the +management of the child in the home, and if, for example, he finds +that the crying and resistance is not confined to going to stool, but +also takes place when the child is put to bed, and very often at +meal-times as well, then it will be safe for him to conclude that all +the symptoms are due to the same cause--a sort of "negativism" which +is apt to appear in all children who are directed and urged too much, +and whose parents are not careful to hide from them the anxiety and +distress which their conduct occasions. + +If this diagnosis is made, then a full and clear explanation should be +given to the mother, or at any rate to such mothers--and fortunately +they are in the majority--who are capable of appreciating the point of +psychology involved, and of correcting the management of the child so +as to overcome the negativism. To attempt treatment by prescribing +drugs, or in any other way than by correcting the faulty management, +is to court failure. As Charcot has said, in functional disorders it +is not so much the prescription which matters as the prescriber. + +But the task of the doctor is often one of even greater difficulty. +Often enough there will be a combination of organic disturbance with +functional trouble. For example, a girl of eighteen years old suffered +from a pain in the left arm which has persisted on and off since the +olecranon had been fractured when she was two years of age. She was +the youngest of a large family, and had never been separated for a day +from the care and apprehensions of her mother. The joint was stiff, +and there was considerable deformity. The pain always increased when +she was tired or unhappy. Again, a girl had some slight cystitis with +frequent micturition, and this passed by slow degrees into a purely +functional irritability of the bladder, which called for micturition +at frequent intervals both by day and night. In such cases treatment +must endeavour to control both factors--the local organic disturbance +must if possible be removed, and the faults of management corrected. + +It is a good physician who can appreciate and estimate accurately the +temperament of his patient, and the need for this insight is nowhere +greater than in dealing with the disorders of childhood. It can be +acquired only by long practice and familiarity with children. In the +hospital wards we shall learn much that is essential, but we shall not +learn this. The child, who is so sensitive to his environment, shows +but little that is characteristic when admitted to an institution. +Only in the nursery can we learn to estimate the influences which +proceed from parents and nurses of different characters and +temperaments, and the reaction which is produced by them in the child. + +The body of the child is moulded and shaped by the environment in +which it grows. Pure air, a rational diet, free movement, give +strength and symmetry to every part. Faults of hygiene debase the +type, although the type is determined by heredity which in the +individual is beyond our control. Mothers and nurses to-day are well +aware of the need for a rational hygiene. Mother-craft is studied +zealously and with success, and there is no lack of books to give +sound guidance and to show the mean between the dangerous extremes of +coddling and a too Spartan exposure. Yet sometimes it has seemed as if +some mothers whose care for their children's physical health is most +painstaking, who have nothing to learn on the question of diet, of +exercise, of fresh air, or of baths, who measure and weigh and record +with great minuteness, have had their attention so wholly occupied +with the care of the body that they do not appreciate the simultaneous +growth of the mind, or inquire after its welfare. Yet it is the +astounding rapidity with which the mental processes develop that forms +the distinguishing characteristic of the infancy of man. Were it not +for this rapid growth of the cerebral functions, the rearing of +children would be a matter almost as simple and uneventful as the +rearing of live stock. For most animals faults of environment must be +very pronounced to do harm by producing mental unrest and +irritability. Thus, indeed, some wild animal separated from its +fellows and kept in solitary captivity may sicken and waste, though +maintained and fed with every care. Yet if the whole conditions of +life for the animal are not profoundly altered, if the environment is +natural or approximately natural, it is as a rule necessary to care +only for its physical needs, and we need not fear that the results +will be spoiled by the reaction of the mind upon the body. But with +the child it is different; airy nurseries, big gardens, visits to the +seaside, and every advantage that money can buy cannot achieve success +if the child's mind is not at rest, if his sleep is broken, if food is +habitually refused or vomited, or if to leave him alone in the nursery +for a moment is to evoke a fit of passionate crying. + +The grown-up person comes eventually to be able to control this +tremendous organ, this brain, which is the predominant feature of his +race. In the child its functions are always unstable and liable to be +upset. Evidence of mental unrest or fatigue, which is only rarely met +with in grown persons and which then betokens serious disturbance of +the mind, is of comparatively common occurrence in little children. +Habit spasm, bed-wetting, sleep-walking, night terrors, and +convulsions are symptoms which are frequent enough in children, and +there is no need to be unduly alarmed at their occurrence. In adult +age they are found only among persons who must be considered as +neuropathic. To make the point clear, I have chosen examples from the +graver and more serious symptoms of nervous unrest. But it is equally +true that minor symptoms which in adults are universally recognised to +be dependent upon cerebral unrest or fatigue are of everyday +occurrence in childhood. Broken and disturbed sleep, absence of +appetite and persistent refusal of food, gastric pain and discomfort +after meals, nervous vomiting, morbid flushing and blushing, headache, +irritability and excessive emotional display, at whatever age they +occur, are indications of a mind that is not at rest. In children, as +in adults, they may be prominent although the physical surroundings of +the patient may be all that could be desired and all that wealth can +procure. It is an everyday experience that business worries and +responsibilities in men, domestic anxieties or childlessness in women, +have the power to ruin health, even in those who habitually or grossly +break none of its laws. The unstable mind of the child is so sensitive +that cerebral fatigue and irritability are produced by causes which +seem to us extraordinarily trivial. In the little life which the child +leads, a life in which the whole seems to us to be comprised in +dressing and undressing, washing, walking, eating, sleeping, and +playing, it is not easy to detect where the elements of nervous +overstrain lie. Nor is it as a rule in these things that the mischief +is to be found. It is in the personality of mother or nurse, in her +conduct to the child, in her actions and words, in the tone of her +voice when she addresses him, even in the thoughts which pass through +her mind and which show themselves plainly to that marvellously acute +intuition of his, which divines what she has not spoken, that we must +seek for the disturbing element. The mental environment of the child +is created by the mother or the nurse. That is her responsibility and +her opportunity. The conduct of the child must be the criterion of her +success. If things go wrong, if there is constant crying or +ungovernable temper, if sleep and food are persistently refused, or if +there is undue timidity and tearfulness, there is danger that seeds +may be sown from which nervous disorders will spring in the future. + +There are many women who, without any deep thought on the matter, have +the inborn knack of managing children, who seem to understand them, +and have a feeling for them. With them, we say, the children are +always good, and they are good because the element of nervous +overstrain has not arisen. There are other women, often very fond of +children, who are conspicuously lacking in this power. Contact with +one of these well-meaning persons, even for a few days, will +demoralise a whole nursery. Tempers grow wild and unruly, sleep +disappears, fretfulness and irritability take its place. Yet of most +mothers it is probably true that they are neither strikingly +proficient nor utterly deficient in the power of managing children. If +they lack the gift that comes naturally to some women, they learn from +experience and grow instinctively to feel when they have made a false +step with the child. Although by dearly bought experience they learn +wisdom in the management of their children, they nevertheless may not +study the subject with the same care which they devote to matters of +diet and hygiene. It is the mother whose education and understanding +best fits her for this task. In this country a separate nursery and a +separate nursery life for the children is found in nearly all +households among the well-to-do, and the care for the physical needs +of the children is largely taken off the mothers' shoulders by nurses +and nursemaids. That this arrangement is advantageous on the whole +cannot be doubted. In America and on the Continent, where the children +often mingle all day in the general life of the household, and occupy +the ordinary living rooms, experience shows that nerve strain and its +attendant evils are more common than with us. Nevertheless, the +arrangement of a separate nursery has its disadvantages. Nurses are +sometimes not sufficiently educated to have much appreciation of the +mental processes of the child. If the children are restless and +nervous they are content to attribute this to naughtiness or to +constipation, or to some other physical ailment. Their time is usually +so fully occupied that they cannot be expected to be very zealous in +reading books on the management of children. Nevertheless, in +practical matters of detail a good nurse will learn rapidly from a +mother who has given some attention to the subject, and who is able to +give explicit instructions upon definite points. + +It is right that mothers should appreciate the important part which +the environment plays in all the mental processes of children, and in +their physical condition as well; that they should understand that +good temper and happiness mean a proper environment, and that constant +crying and fretfulness, broken sleep, refusal of food, vomiting, undue +thinness, and extreme timidity often indicate that something in this +direction is at fault. + +Nevertheless, we must be careful not to overstate our case. We must +remember how great is the diversity of temperament in children--a +diversity which is produced purely by hereditary factors. The task of +all mothers is by no means of equal difficulty. There are children in +whom quite gross faults in training produce but little permanent +damage; there are others of so sensitive a nervous organisation that +their environment requires the most delicate adjustment, and when +matters have gone wrong, it may be very difficult to restore health of +mind and body. When a peculiarly nervous temperament is inherited, +wisdom in the management of the child is essential, and may sometimes +achieve the happiest results. Heredity is so powerful a factor in the +development of the nervous organisation of the child that, realising +its importance, we should be sparing in our criticism of the results +which the mothers who consult us achieve in the training of their +children. A sensitive, nervous organisation is often the mark of +intellectual possibilities above the average, and the children who are +cast outside the ordinary mould, who are the most wayward, the most +intractable, who react to trifling faults of management with the most +striking symptoms of disturbance, are often those with the greatest +potentialities for achievement and for good. It is natural for the +mother of placid, contented, and perhaps rather unenterprising +children, looking on as a detached outsider, seeing nothing of the +teeming activities of the quick, restless little brain, and the +persistent, though faulty reasoning--it is natural for her to blame +another's work, and to flatter herself that her own routine would have +avoided all these troublesome complications. The mother of the nervous +child may often rightly take comfort in the thought that her child is +worth the extra trouble and the extra care which he demands, because +he is sent into the world with mechanism which, just because it is +more powerful than the common run, is more difficult to master and +takes longer to control and to apply for useful ends. + +It is through the mother, and by means of her alone, that the doctor +can influence the conduct of the child. Without her co-operation, or +if she fails to appreciate the whole situation, with the best will in +the world, we are powerless to help. Fortunately with the majority of +educated mothers there is no difficulty. Their powers of observation +in all matters concerning their children are usually very great. It is +their interpretation of what they have observed that is often faulty. +Thus, in the example given above, the mother observes correctly that +defæcation is inhibited, and produces crying and resistance. It is +her interpretation that the cause is to be found in pain that is at +fault. Again, a mother may bring her infant for tongue-tie. She has +observed correctly that the child is unable to sustain the suction +necessary for efficient lactation, and has hit upon this fanciful and +traditional explanation. The doctor, who knows that the tongue takes +no part in the act of sucking, will probably be able to demonstrate +that the failure to suck is due to nasal obstruction, and that the +child is forced to let go the nipple because respiration is impeded. +The opportunities for close observation of the child which mothers +enjoy are so great that we shall not often be justified in +disregarding their statements. But if we are able to give the true +explanation of the symptoms, it will seldom happen that the mother +will fail to be convinced, because the explanation, if true, will fit +accurately with all that has been observed. Thus the mother of the +child in whom defæcation is inhibited by negativism may have made +further observations. For example, she may have noted that the +so-called constipation causes fretfulness, that it is almost always +benefited by a visit to the country or seaside, or that it has become +much worse since a new nurse, who is much distressed by it, has taken +over the management of the child. To this mother the explanation must +be extended to fit these observations, of the accuracy of which there +need be no doubt. Fretfulness and negativism with all children whose +management is at fault come in waves and cycles. The child, naughty +and almost unmanageable one week, may behave as a model of propriety +the next. The negativism and refusal to go to stool are the outcome of +the nervous unrest, not its cause. Again, the nervous child, like the +adult neuropath, very often improves for the time being with every +change of scene and surroundings. It is the _ennui_ and monotony of +daily existence, in contact with the same restricted circle, that +becomes insupportable and brings into prominence the lack of moral +discipline, the fretfulness, and spirit of opposition. Lastly, the +conduct of the nervous child is determined to a great extent by +suggestions derived from the grown-up people around him. Refusal of +food, refusal of sleep, refusal to go to stool, as we shall see later, +only become frequent or habitual when the child's conduct visibly +distresses the nurse or mother, and when the child fully appreciates +the stir which he is creating. The mother will readily understand that +in such a case, where constipation varies in degree according as +different persons take charge of the child, the explanation offered is +that which alone fits with the observed facts. A full and free +discussion between mother and doctor, repeated it may be more than +once, may be necessary before the truth is arrived at, and a line of +action decided upon. Only so can the doctor, remote as he is from the +environment of the child, intervene to mould its nature and shape its +conduct. + +If the doctor is to fit himself to give advice of this sort, he must +be a close observer of little children. He must not consider it +beneath his dignity to study nursery life and nursery ways. There he +will find the very beginnings of things, the growing point, as it +were, of all neuropathy. A man of fifty, who in many other ways showed +evidence of a highly nervous temperament, had especially one +well-marked phobia, the fear of falling downstairs. It had never been +absent all his life, and he had grown used to making the descent of +the stairs clinging firmly to the stair-rail. Family tradition +assigned this infirmity to a fall downstairs in early childhood. But +all children fall downstairs and are none the worse. The persistence +of the fear was due, I make no doubt, to the attitude of the parents +or nurse, who made much of the accident, impressed the occasion +strongly on the child's memory, and surrounded him thereafter with +precautions which sapped his confidence and fanned his fears. + +In what follows we will consider first the subject of nursery +management, searching in it for the origin of the common disorders of +conduct both of childhood and of later life. I have grouped these +nursery observations under the heads of four characteristic features +of the child's psychology--his Imitativeness, his Suggestibility, his +Love of Power, and his acute though limited Reasoning Faculties. I +feel that some such brief examination is necessary if we are to +understand correctly the ætiology of some of the most troublesome +disorders of childhood, such as enuresis, anorexia, dyspepsia, or +constipation, disorders in which the nervous element is perhaps to-day +not sufficiently emphasised. Finally, we can evolve a kind of nursery +psycho-therapeutics--a subject which is not only of fascinating +interest in itself, but which repays consideration by the success +which it brings to our efforts to cure and control. + + + + +CHAPTER II + +OBSERVATIONS IN THE NURSERY + + +_(a)_ THE IMITATIVENESS OF THE CHILD + +It is in the second and third years of the child's life that the +rapidity of the development of the mental processes is most apparent, +and it is with that age that we may begin a closer examination. At +first sight it might seem more reasonable to adopt a strictly +chronological order, and to start with the infant from the day of his +birth. Since, however, we can only interpret the mind of the child by +our knowledge of our own mental processes, the study of the older +child and of the later stages is in reality the simpler task. The +younger the infant, the greater the difficulties become, so that our +task is not so much to trace the development of a process from simple +and early forms to those which are later and more complex, as to +follow a track which is comparatively plain in later childhood, but +grows faint as the beginnings of life are approached. + +At the age, then, of two or three the first quality of the child which +may arrest our attention is his extreme imitativeness. Not that the +imitation on his part is in any way conscious; but like a mirror he +reflects in every action and in every word all that he sees and hears +going on around him. We must recognise that in these early days his +words and actions are not an independent growth, with roots in his own +consciousness, but are often only the reflection of the words and +actions of others. How completely speech is imitative is shown by the +readiness with which a child contracts the local accent of his +birthplace. The London parents awake with horror to find their baby an +indubitable Cockney; the speech of the child bred beyond the Tweed +proclaims him a veritable Scot. Again, some people are apt to adopt a +somewhat peremptory tone in addressing little children. Often they do +not trouble to give to their voices that polite or deferential +inflection which they habitually use when speaking to older people. +Listen to a party of nurses in the Park addressing their charges. As +if they knew that their commands have small chance of being obeyed, +they shout them with incisive force. "Come along at once when I tell +you," they say. And the child faithfully reflects it all back, and is +heard ordering his little sister about like a drill sergeant, or +curtly bidding his grandmother change her seat to suit his pleasure. +If we are to have pretty phrases and tones of voice, mothers must see +to it that the child habitually hears no other. Again, mothers will +complain that their child is deaf, or, at any rate, that he has the +bad habit of responding to all remarks addressed to him by saying, +"What?" or, worse still, "Eh?" Often enough the reason that he does so +is not that the child is deaf, nor that he is particularly slow to +understand, but simply that he himself speaks so indistinctly that no +matter what he says to the grown-up people around him, they bend over +him and themselves utter the objectionable word. + +We all hate the tell-tale child, and when a boy comes in from his walk +and has much to say of the wicked behaviour of his little sister on +the afternoon's outing, his mother is apt to see in this a most horrid +tendency towards tale-bearing and currying of favour. She does not +realise that day by day, when the children have come in from their +walk, she has asked nurse in their hearing if they have been good +children; and when, as often happens, they have not, the nurse has +duly recounted their shortcomings, with the laudable notion of putting +them to shame, and of emphasising to them the wickedness of their +backsliding--and this son of hers is no hypocrite, but speaks only, as +all children speak, in faithful reproduction of all that he hears. +Those grown-up persons who are in charge of the children must realise +that the child's vocabulary is their vocabulary, not his own. It is +unfortunate, but I think not unavoidable, that so often almost the +earliest words that the infant learns to speak are words of reproof, +or chiding, or repression. The baby scolds himself with gusto, +uttering reproof in the very tone of his elders: "No, no," "Naughty," +or "Dirty," or "Baby shocked." + +Speech, then, is imitative from the first, if we except the early baby +sounds with reduplication of consonants to which in course of time +definite meaning becomes attached, as "Ba-ba," "Ma-ma," "Na-na," +"Ta-ta," and so forth. Action only becomes imitative at a somewhat +later stage. The first purposive movements of the child's limbs are +carried out in order to evoke tactile sensations. He delights to +stimulate and develop the sense of touch. At first he has no knowledge +of distance, and his reach exceeds his grasp. He will strain to touch +and hold distant objects. Gradually he learns the limitations of +space, and will pick up and hold an object in his hand with precision. +Often he conveys everything to his mouth, not because his teeth are +worrying him, or because he is hungry, as we hear sometimes alleged, +but because his mouth, lips, and tongue are more sensitive, because +more plentifully furnished with the nerves of tactile sensation. By +constant practice the sense of touch and the precision of the movement +of his hands are slowly developed, and not these alone, for the child +in acquiring these powers has developed also the centres in the brain +which control the voluntary movements. When the child can walk he +continues these grasping and touching exercises in a wider sphere. As +the child of fifteen or eighteen months moves about the room, no +object within his reach is passed by. He stretches out his hand to +touch and seize upon everything, and to experience the joy of +imparting motion to it. The impulse to develop tactile sensation and +precision in the movements of his hands compels him with irresistible +force. It is foolish to attempt to repress it. It is foolish, because +it is a necessary phase in his development, and moreover a passing +phase. No doubt it is annoying to his elders while it lasts, but the +only wise course is to try to thwart as little as we can his +legitimate desire to hold and grasp the objects, and even to assist +him in every way possible. But the mother must assist him only by +allowing free play to his attempts. To hand him the object is to +deprive the exercise of most of its value. Incidentally she may teach +him the virtue of putting things back in their proper places, an +accomplishment in which he will soon grow to take a proper pride. If +she attempts continually to turn him from his purpose, reproving him +and snatching things from him, she prolongs the grasping phase beyond +its usual limits. And she does a worse thing at the same time. Lest +the quicker hands of his nurse should intervene to snatch the prize +away before he has grasped it, he too learns to snatch, with a sudden +clumsy movement that overturns, or breaks, or spills. If left to +himself he will soon acquire the dexterity he desires. He may overturn +objects at first, or let them fall, but this he regards as failure, +which he soon overcomes. A child of twenty months, whose development +in this particular way has not been impeded by unwise repression, will +pick out the object on which he has set his heart, play with it, +finger it, and replace it, and he will do it deliberately and +carefully, with a clear desire to avoid mishap. Dr. Montessori, who +has developed into a system the art of teaching young children to +learn precision of movement and to develop the nerve centres which +control movement, tells in her book a story which well illustrates +this point.[1] + +[Footnote 1: _The Montessori Method_, pp. 84, 85.] + +"The directress of the Casa del Bambini at Milan constructed under one +of the windows a long, narrow shelf, upon which she placed the little +tables containing the metal geometric forms used in the first lesson +in design. But the shelf was too narrow, and it often happened that +the children in selecting the pieces which they wished to use would +allow one of the little tables to fall to the floor, thus upsetting +with great noise all the metal pieces which it held. The directress +intended to have the shelf changed, but the carpenter was slow in +coming, and while waiting for him she discovered that the children had +learned to handle these materials so carefully that in spite of the +narrow and sloping shelf, the little tables no longer fell to the +ground. The children, by carefully directing their movements, had +overcome the defect in this piece of furniture." + +By slow degrees the child learns to command his movements. If his +efforts are aided and not thwarted, before he is two years old he will +have become capable of conducting himself correctly, yet with perfect +freedom. The worst result of the continual repression which may be +constantly practised in the mistaken belief that the grasping phase is +a bad habit which persistent opposition will eradicate, is the nervous +unrest and irritation which it produces in the child. A passionate fit +of crying is too often the result of the thwarting of his nature, and +the same process repeated over and over again, day by day, almost hour +by hour, is apt to leave its mark in unsatisfied longing, +irritability, and unrest. Above all, the child requires liberty of +action. + +We have here an admirable example of the effect of environment in +developing the child's powers. A caged animal is a creature deprived +of the stimulus of environment, and bereft therefore to a great extent +of the skill which we call instinct, by which it procures its food, +guarantees its safety from attack, constructs its home, cares for its +young, and procreates its species. If, metaphorically speaking, we +encircle the child with a cage, if we constantly intervene to +interpose something between him and the stimulus of his environment, +his characteristic powers are kept in abeyance or retarded, just as +the marvellous instinct of the wild animals becomes less efficient in +captivity. + +The grasping phase is but a preliminary to more complex activities. +Just as in schooldays we were taught with much labour to make +pot-hooks and hangers efficiently before we were promoted to real +attempts at writing, so before the child can really perform tasks with +a definite meaning and purpose, he must learn to control the finer +movements of his hands. Once the grasping phase, the stage of +pot-hooks, is successfully past--and the end of the second year in a +well-managed child should see its close--the child sets himself with +enthusiasm to wider tasks. To him washing and dressing, fetching his +shoes and buttoning his gaiters, all the processes of his simple +little life, should be matters of the most enthralling interest, in +which he is eager to take his part and increasingly capable of doing +so. In the Montessori system there is provided an elaborate apparatus, +the didactic material, designed to cultivate tactile sensation and the +perception of sense stimuli. It will generally suffice to advise the +mother to make use of the ordinary apparatus of the nursery. The +imitativeness of the young child is so great that he will repeat in +almost every detail all the actions of his nurse as she carries out +the daily routine. At eighteen months of age, when the electric light +is turned on in his nursery, the child will at once go to the curtains +and make attempts to draw them. At the same age a little girl will +weigh her doll in her own weighing-machine, will take every precaution +that the nurse takes in her own case, and will even stoop down +anxiously to peer at the dial, just as she has seen her mother and +nurse do on the weekly weighing night. But at a very early age +children appreciate the difference between the real and the +make-believe. They desire above all things to do acts of real service. +At the age of two a child should know where every article for the +nursery table is kept. He will fetch the tablecloth and help to put it +in place, spoons and cups and saucers will be carried carefully to the +table, and when the meal is over he will want to help to clear it all +away. All this is to him a great delight, and the good nurse will +encourage it in the children, because she sees that in doing so they +gain quickness and dexterity and poise of body. The first purposive +movements of the child should be welcomed and encouraged. It is +foolish and wrong to repress them, as many nurses do, because the +child in his attempts gets in the way, and no doubt for a time delays +rather than expedites preparations. The child who is made to sit +immobile in his chair while everything is done for him is losing +precious hours of learning and of practice. It is useless, and to my +mind a little distasteful, to substitute for all this wonderful child +activity the artificial symbolism of the kindergarten school in which +children are taught to sing songs or go through certain semi-dramatic +activities which savour too much of a performance acquired by precise +instruction. If such accomplishments are desired, they may be added +to, but they must not replace, the more workaday activities of the +little child. The child whose impulses towards purposive action are +encouraged is generally a happy child, with a mind at rest. When those +impulses are restrained, mental unrest and irritability are apt to +appear, and toys and picture books and kindergarten games will not be +sufficient to restore his natural peace of mind. + + +_(b)_ THE SUGGESTIBILITY OF THE CHILD + +We may pass from considering the imitativeness of the child to study a +second and closely related quality, his suggestibility. His conception +of himself as a separate individual, of his ego, only gradually +emerges. It is profoundly modified by ideas derived from those around +him. Because of his lack of acquired experience, there is in the child +an extreme sensitiveness to impressions from outside. Take, for +example, a matter that is sometimes one of great difficulty, the +child's likes and dislikes for food. Many mothers make complaint that +there are innumerable articles of diet which the child will not take: +that he will not drink milk, or that he will not eat fat, or meat, or +vegetables, or milk puddings. There are people who believe that these +peculiarities of taste correspond with idiosyncrasies of digestion, +and that children instinctively turn from what would do them harm. I +do not believe that there is much truth in this contention. If we +watch an infant after weaning, at the time when his diet is gradually +being enlarged to include more solid food, with new and varied +flavours, we may see his attention arrested by the strange sensations. +With solid or crisp food there may be a good deal of hesitation and +fumbling before he sets himself to masticate and swallow. With the +unaccustomed flavour of gravy or fruit juice there may be seen on his +face a look of hesitation or surprise. In the stolid and placid child +these manifestations are as a rule but little marked, and pleasurable +sensations clearly predominate. With children of more nervous +temperament it is clear that sensations of taste are much more acute. +Even in earliest infancy, children have a way of proclaiming their +nervous inheritance by the repugnance which they show to even trifling +changes in the taste or composition of their food. We see the same +sensitiveness in their behaviour to medicines. The mixture which one +child will swallow without resentment, and almost eagerly, provokes +every expression of disgust from another, or is even vomited at once. +In piloting the child through this phase, during which he starts +nervously at all unaccustomed sensations and flavours, the attitude of +mother and nurse is of supreme importance. It is unwise to attempt +force; it is equally unwise, by excessive coaxing, cajoling, and +entreaty, to concentrate the child's attention on the matter. If +either is tried every meal is apt to become a signal for struggling +and tears. The phase, whether it is short or long continued, must be +accepted as in the natural order of things, and patience will see its +end. The management of this symptom,--refusal of food and an +apparently complete absence of desire for food,--which is almost the +commonest neurosis of childhood, will be dealt with later. Here it is +mentioned because I wish to emphasise that if too much is made of a +passing hesitation over any one article of food, if it becomes the +belief of the mother or nurse that a strong distaste is present, then +if she is not careful her attitude in offering it, because she is +apprehensive of refusal, will exert a powerful suggestion on the +child's mind. Still worse, it may cause words to be used in the +child's hearing referring to this peculiarity of his. By frequent +repetition it becomes fixed in his mind that this is part of his own +individuality. He sees himself--and takes great pleasure in the +thought--as a strange child, who by these peculiarities creates +considerable interest in the minds of the grown-up people around him. +When the suggestion takes root it becomes fixed, and as likely as not +it will persist for his lifetime. It may be habitually said of a child +that, unlike his brothers and sisters, he will never eat bananas, and +thereafter till the day of his death he may feel it almost a physical +impossibility to gulp down a morsel of the offending fruit. So, too, +there are people who can bolt their food with the best of us, who yet +declare themselves incapable of swallowing a pill. + +Another example of the force of suggestion, whether unconscious or +openly exercised by speech, is given us in the matter of sleep. Among +adults the act of going to bed serves as a powerful suggestion to +induce sleep. Seldom do we seek rest so tired physically that we drop +off to sleep from the irresistible force of sheer exhaustion. Yet as +soon as the healthy man whose mind is at peace, whose nerves are not +on edge, finds himself in bed, his eyes close almost with the force of +a hypnotic suggestion, and he drops off to sleep. With some of us the +suggestion is only powerful in our own bed, that on which it has acted +on unnumbered nights. We cannot, as we say, sleep in a strange bed. It +is suggestion, not direct will power, that acts. No one can absolutely +will himself to sleep. In insomnia it is the attempt to replace the +unconscious auto-suggestion by a conscious voluntary effort of will +that causes the difficulty. A thousand times in the night we resolve +that now we _will_ sleep. If we could but cease to make these +fruitless efforts, sleep might come of itself and the suggestion or +habit be re-established. + +In little children the suggestion of sleep, provoked by being placed +in bed, sometimes acts very irregularly. Often it may succeed for a +week or two, and then some untoward happening breaks the habit, and +night after night, for a long time, sleep is refused. The wakeful +child put to bed, resents the process, and cries and sobs miserably, +to the infinite distress of his mother. It then becomes just as likely +that the child will connect his bed in his mind, not with rest and +sleep, but with sobbing and crying on his part, and mingled entreaties +and scoldings from his nurse or mother. An important part in this +perversion of the suggestion is played by the attitude of the person +who puts the child to bed. Often the nurse is uniformly successful, +while the mother, who is perhaps more distressed by the sobbing of the +child, as consistently fails, because she has been unable to hide her +apprehension from him, and has conveyed to his mind a sense of his own +power. + +Just in the same way, grown-up people, filled with anxiety because of +the helplessness of the young child, unable to divest their minds of +the fears of the hundred and one accidents that may befall, or that +within their own experience have befallen, a little child at one time +or another, unconsciously make unwise suggestions which fill his mind +with apprehension and terror. They do not like their children to show +fear of animals. Nor would they if it were not that their own +apprehension that the child may be hurt communicates itself to him. +The child is not of himself afraid to fall, it is they who suffer the +anxiety and show it by treating the fall as a disaster. The child is +not of himself afraid to be left alone in a room. It is they who sap +his confidence in himself, because they do not venture to leave him +out of their sight, from a nameless dread of what may happen. A little +girl cut her finger and ran to her nurse, pleased and interested: +"See," she said, seeing it bleed, "fingers all jammy." Only when the +nurse grasped her with unwise expressions of horror did she break into +cries of fear. A town-bred nurse, who is afraid of cows, will make +every country walk an ordeal of fear for the children. + +Every mother must be made to realise the ease with which these +unconscious suggestions act upon the mind of the little child, and +should school herself to be strong to make her child strong, and to +see to it that all this suggestive force is utilised for good and not +for evil. + +It is upon this susceptibility to suggestion that a great part of his +early education reposes. No one who is incapable of profiting by this +natural disposition of the child can be successful in her management +of him. Turn where you will in his daily life the influence of this +force of suggestion is clearly apparent. The child does without +questioning that which he is confidently expected to do. Thus he will +eat what is given him, and sleep soundly when he is put to bed if only +the appropriate suggestion and not the contrary is made to him. Again +we have seen that a perversion of suggestion of this sort is a common +source of constipation in early childhood. If the child's attention is +directed towards the difficulty, if he is urged or ordered or appealed +to to perform his part, if failure is looked upon as a serious +misfortune, the bowels may remain obstinately unmoved. In children as +in adults a too great concentration of attention inhibits the action +of the bowels, and constipation, in many persons, is due to the +attempt to substitute will power for the force of habitual suggestion. +No matter what other treatment we adopt, the mother must be careful to +hide from the child that his failure is distressing to her. A cheerful +optimism which teaches him to regard himself as one who is +conspicuously regular in his habits, and who has a reputation in this +respect to live up to is sure to succeed. To talk before him of his +habitual constipation, and to worry over the difficulty, is as surely +to fail. In the same way unwise suggestion can interfere with the +passing of water at regular and suitable intervals. There are children +who constantly desire to pass water on any occasion, which is +conspicuously inappropriate, because their attention has been +concentrated on the sensations in the bladder. Often enough when at +great inconvenience opportunity has been found, the desire has passed +away, and all the trouble has proved needless. It is not too much to +say that every occupation and every action of the day can be made +delightful or hateful to the child, according to the suggestion with +which it is presented and introduced. Dressing and undressing, eating +and drinking, bathing, washing, the putting away of toys, even going +to bed, can be made matters of enthralling interest or delight, or a +subject for tears and opposition, according to the bias which is given +to the child's mind by the words, attitude, and actions of nurses and +mothers. + +Here we approach very near to the heart of the subject. Stripped of +all that is not essential we see the problem of the management of +children reduced to the interplay between the adult mind and the mind +of the receptive suggestible child. That which is thought of and +feared for the child, that he rapidly becomes. Placid, comfortable +people who do not worry about their children find their children +sensible and easy to manage. Parents who take a pride in the daring +and naughty pranks of their children unconsciously convey the +suggestion to their minds that such conduct is characteristic of them. +Nervous and apprehensive parents who are distressed when the child +refuses to eat or to sleep, and who worry all day long over possible +sources of danger to him, are forced to watch their child acquire a +reputation for nervousness, which, as always, is passively accepted +and consistently acted up to. Differences in type, determined by +hereditary factors, no doubt, exist and are often strongly marked. Yet +it is not untrue to say that variations in children, dependent upon +heredity, show chiefly in the relative susceptibility or +insusceptibility of the child to the influences of environment and +management. It is no easy task to distinguish between the nervous +child and the child of the nervous mother, between the child who +inherits an unusually sensitive nervous system and the child who is +nervous only because he breathes constantly an atmosphere charged with +doubt and anxiety. + + +(_c_) THE CHILD'S LOVE OF POWER + +Let us study briefly a third quality of the child which, for want of a +better name, I have called after the ruling passion of mankind, his +love of power. Perhaps it would be better to call it his love of being +in the centre of the picture. It is his constant desire to make his +environment revolve around him and to attract all attention to +himself. Somewhat later in life this desire to attract attention, at +all costs, is well seen in the type of girl popularly regarded as +hysterical. The impulse is then a morbid and debased impulse; in the +child it is natural and, within limits, praiseworthy. A girl of this +sort, who feels that she is not likely to attract attention because of +any special gifts of beauty or intellect which she may possess, +becomes conscious that she can always arouse interest by the severity +of her bodily sufferings. The suggestion acts upon her unstable mind, +and forthwith she becomes paralysed, or a cripple, or dumb, presenting +a mimicry or travesty of some bodily ailment with which she is more or +less familiar. "Hysterical" girls will even apply caustic to the skin +in order to produce some strange eruption which, while it sorely +puzzles us doctors, will excite widespread interest and commiseration. +Now little children will seldom carry their desire to attract +attention so far as to work upon the feelings of their parents by +simulating disease. They have not the necessary knowledge to play the +part, and even if they make the attempt, complaining of this or that +symptom which they notice has aroused the interest of their elders, +the simulation is not likely to be so successful as to deceive even a +superficial observer. But within the limits of their own powers, +children are past masters in attracting attention. The little child is +unable to take part in any sustained conversation; most of his +talking, indeed, is done when he is alone, and is addressed to no one +in particular. But he knows well that by a given action he can produce +a given reaction in his mother and nurse. A great part of what is said +to him--too great a part by far--comes under the category of reproof +or repression. He is forbidden to do this or that, coaxed, cajoled, +threatened long before he is old enough to understand the meaning of +the words spoken, although he knows the tone in which they are uttered +and loves to produce it at will. How he enjoys it all! Watch him draw +near the fire, the one place that is forbidden him. He does not mean +to do himself harm. He knows that it is hot and would hurt him, but +for the time being he is out of the picture and he is intent on +producing the expected response, the reproof tone from his mother +which he knows so well. He approaches it warily, often anticipating +his mother's part and vigorously scolding himself. He desires nothing +more than that his mother should repeat the reproof, forbidding him a +dozen times. The mind of all little children tends easily to work in a +groove. It delights in repetition and it evoking not the unexpected +but the expected. If his sport is stopped by his mother losing +patience and removing him bodily from the danger zone, his sense of +impotence finds vent in passionate crying. But if his mother takes no +notice, the sport soon loses its savour. He is conscious that somehow +or other it has fallen flat, and he flits off to other employment. + +Mothers will complain that children seem to take a perverse pleasure +in evoking reproof, appeals, entreaties, and exhortations. A small boy +of four who had several times repeated the particular sin to which his +attention had been directed by the frequency of his mother's warnings +and entreaties, finding that on this occasion she had decided to take +no notice, approached her with a troubled face: "Are you not angry?" +he said; "are you not disappointed?" In reality the naughty child is +often only the child who has become master of his mother's or his +nurse's responses, and can produce at will the effect he desires. The +idea that the child possesses a strong will, which can and must be +broken by persistent opposition, is based upon this tendency of the +child. It is an entire misconception of the situation: Strength of +will and fixity of purpose are among the last powers which the human +mind develops. In little children they are conspicuously absent. What +appears to us as a fixed and persistent desire to perform a definite +action in spite of all we can say or do, is often no more than the +desire to produce the familiar tones of reproof, to traverse again the +familiar ground, to attract attention and to find himself again the +centre of the picture. If no one pays any attention and no one +reproves, he soon gives up the attempt. If too much is made of any one +action of the child, a strong impression is made on his mind and he +cannot choose but return to it again and again. + +This little drama of the fireplace may teach us a great deal in the +management of children. The wise mother and nurse will find a hundred +devices to catch the child's attention and lure him away from the +danger zone without the incident making any impression on his mind at +all, and will not call attention to it by repeated reproofs or +warnings which will certainly lead him straight back to the spot. + +In matters of greater moment the same impulse to oppose the will of +those around him is seen. In considering the point of the child's +susceptibility to suggestion, we have mentioned the refusal of sleep +and the refusal of food. In both it is possible to detect the +influence of this pronounced force of opposition. As the child lies +sobbing or screaming in bed, every new approach to him, every fresh +attempt at pacification, renews the force of his opposition in a +crescendo of sound. But it is in his refusal of food that the child is +apt to find his chief opportunity. Meal-times degenerate into a +struggle. There at least he can show his complete mastery of the +situation. No one can swallow his food for him, and he knows it. He +can clench his teeth and shake his head and obstinately refuse every +morsel offered. He can hold food in his mouth for half an hour at a +time and remain deaf to all the appeals of his helpless nurse. If she +tries force, he quells the attempt by a storm of crying. If she +declines upon entreaty and coaxing, he will not be persuaded. It is +the little scene of the fireplace over again. The attempts at force or +the attempts at persuasion, by making much of it, have concentrated +the attention of the child upon the difficulty, and have taught him +his own power to dominate the situation. + +It is right that parents should realise that the disturbing and +irritating element in the child's environment is nearly always +provided by the intrusion of the adult mind and its contact with the +child's. Some supervision and some intrusion, therefore, is of course +absolutely necessary, but the best-regulated nursery is that in which +it is least evident. Something is definitely wrong if a child of two +years will not play for half an hour at a time happily and busily in a +room by himself. It is an even better test if the child will play +amicably by himself with nurse or mother in the room, without the two +parties crossing swords on a single occasion, without reproof or +repression on the one side or undue attempts to attract attention on +the other. If the child is entirely dependent upon the participation +of grown-up persons in his pursuits, then not only do those pursuits +lose much of their educative force, but they become a positive source +of danger because of the constant interplay of personality with +personality. The child who, seated on the ground, will play with his +toys by himself, rises with a brain that is stimulated but not +exhausted. Only very rarely do we find that solitary play, or play +between children, is too exciting. In older children of very quick +intelligence and nervous temperament we occasionally find that the +pace which they themselves set is too exciting or exhausting. I recall +a little boy of seven, an only child of particularly wise and +thoughtful parents, who was brought to me with the complaint that he +exhausted himself utterly both in body and mind by the intense nervous +energy which he threw into his pursuits. For instance, he had been +interested in the maps illustrating the various fronts in the European +War, with which the walls of his father's study were hung, and +although left entirely by himself he had become intensely excited and +exhausted by the eagerness with which he had spent a whole morning, +with a wealth of imaginative force, in drawing a map of the garden of +his house and converting it into the likeness of a war map, filled +with imaginary Army Corps. Such excessive expenditure of nervous force +is unusual even in older children, and as in this case is found +usually only when there is a pronounced nervous inheritance. In little +children in the nursery, solitary play or play between themselves +seldom produces nervous exhaustion. It is quite otherwise when the +child is dependent to a too great extent upon the participation of +adults. It is almost impossible for the mother and nurse not to take +the leading part in the exchange of ideas, and no matter what may be +their good intentions, the pace set is apt to be too great. +Environment, without the intrusion of the adult mind, is best able to +adjust the necessary stimulus and produce development without +exhaustion. Play with grown-up persons, the reading aloud of story +books, the showing of pictures, and so forth, undoubtedly have their +own importance, but they should be confined within strict limits and +to a definite hour in the daily routine. There is sometimes too great +a tendency for parents to make playthings of their little children. +Save at stated times, they must curb their desire to join in their +games, to gather them in their arms, to hold them on their knee, while +they stimulate their minds by a constant succession of new +impressions. With an only child, whose existence is the single +preoccupation of the nurse and mother, and, often enough, of the +father as well, it is difficult to avoid this fault. Yet, if wisdom is +not learnt, the damage to the child may be distressingly serious. He +rapidly grows incapable of supporting life without this excessive +stimulation. Without the constant society and attention of a grown +person, he feels himself lost. He cannot be left alone, and yet cannot +enjoy the society he craves. He grows more and more restless, +dominating the whole situation more and more, constantly plucking at +his nurse's skirts, perversely refusing every new sensation that is +offered him to still his restlessness for a moment. The result of all +this stimulation is mental irritability and exhaustion, which in turn +is often the direct cause of refusal of food, dyspepsia, wakefulness, +and excessive crying. + +The devices by which children will attract to themselves the +attention of their elders, and which, if successful, are repeated with +an almost insane persistence, take on the most varied forms. Sometimes +the child persistently makes use of an expression, or asks questions, +which produce a pleasant stir of shocked surprise and renewed reproofs +and expostulations. One little boy shouted the word "stomachs" with +unwearied persistence for many weeks together. A little girl dismayed +her parents and continued in spite of all they could do to prevent her +to ask every one if they were about to pass water. + +Disorders of conduct of this sort are not really difficult to control. +Suitable punishment will succeed, provided also that the child is +deprived of the sense of satisfaction which he has in the interest +which his conduct excites. His behaviour is only of importance because +it indicates certain faults in his environment and a certain element +of nervous unrest and overstrain. + +The young child demands from his environment that it should give him +two things--security and liberty. He must have security from shocks to +his nervous system. It is true that from the greater shocks the +children of the well-to-do are as a rule carefully guarded. No one +threatens or ill-uses them. They are not terrified by drunken brawls +or scenes of passion. They are not made fearful by the superstitions +of ignorant people. Nevertheless, by the summation of stimuli little +emotions constantly repeated can have effects no less grave upon +their nervous system. From this constantly acting irritation the child +needs security. In the second place, he requires liberty to develop +his own initiative, which should be stimulated and sustained and +directed. Without liberty and without security conduct cannot fail to +become abnormal. + + +(_d_) THE REASONING POWER OF THE CHILD + +Before we proceed to a closer examination of the various symptoms of +nervous unrest in detail, we may very briefly consider the scope and +power of the child's understanding. As a rule I am sure that it is +grossly underestimated. The mental processes of the child are far +ahead of his power of speech. The capacity for understanding speech is +well advanced, and an appeal to reason is often successful while the +child is still powerless to express his own thoughts in words. Because +he cannot so express himself there is a tendency to underestimate the +acuteness of his reasoning, to talk down to him, and to imagine that +he can be imposed upon by any fiction which seems likely to suit the +purpose of the moment. A child of eighteen months is not too young to +be talked to in a quiet, straightforward, sensible way. Only if he is +treated as a reasonable being can we expect his reasoning faculties to +develop. Children dislike intensely the unexplained intervention of +force. If a pair of scissors, left by an oversight lying about, has +been grasped, the first impulse of the mother is to snatch the danger +hurriedly from the child's hands, and her action will generally be +followed by resistance and a storm of weeping. She will do better to +approach him quietly, telling him that scissors hurt babies, and show +him where to place them out of harm's way. Watch a child at play after +his midday meal. He has been out in his perambulator half the morning, +and for the other half has been deep in his midday sleep. Now that +dinner is over he is for a moment master of his time and busily +engaged in some pursuit dear to his heart. At two o'clock inexorable +routine ordains that he must again be placed in the perambulator and +wheeled forth on a fresh expedition. If the nurse does not know her +business she will swoop down upon him, place him on her knee, and +begin to envelop his struggling little body in his outdoor clothes, +scolding his naughtiness as he kicks and screams. If she has a way +with children she will open the cupboard door and call on him to help +find his gaiters and his shoes because it is time for his walk. In a +moment he will leave his toys, forgetting all about them in the joy of +this new activity. + +If the reason for things is explained to children they grow quick to +understand quite complicated explanations. A little girl, not yet two, +was playing with her Noah's Ark on the dining-room table with its +polished surface. The mother interposed a cloth, explaining that the +animals would scratch the table if the cloth were not there. Within a +few minutes the child twice lifted the cloth, peering under it and +saying, "Not scratch table." Yet how often do we find +facetiously-minded persons confound their reasoning and confuse their +judgment by foolish speeches and cock-and-bull tales, which, just +because of their foolishness, seem to them well adapted to the infant +intelligence. + +An attempt to deceive the child is almost always wrong, and because of +our tendency to underestimate the child's intelligence it generally +fails. If a little girl has a sore throat, and the doctor comes to see +her, she knows quite well that she is the prospective patient. It is +useless for the mother to begin proceedings by trying to convince her +that this is not so--that mother has a sore throat too. Such a plan +only arouses apprehension, because the child scents danger in the +artifice. + +Closely connected with the reasoning powers of the child is the +difficult question of the growth of his appreciation of right and +wrong, or, to put it in another way, the growth of obedience or +disobedience. Sooner or later the child must learn to obey; on that +there can be no two opinions. Nevertheless, I think there can be no +doubt that far more harm is done by an over-emphasis of authority than +by its neglect. If the nurse or mother is of strong character, and the +authority is exercised persistently and remorselessly, so that the +whole life of the child is dominated, much as the recruit's existence +in the barrack yard is dominated by the drill sergeant, his +independence of nature is crushed. He is certain to become a +colourless and uninteresting child; he runs a grave risk of growing +sly, broken-spirited, and a currier of favour. If a child is +ruthlessly punished for disobedience from his earliest years, there +is, it need hardly be said, a grave risk that he will learn to lie to +save his skin. I have seen a few such cases of what I may call the +remorseless exercise of authority, and the result has not been +pleasing. Fortunately, perhaps, not many women have the heart to adopt +this attitude to the waywardness of little children--a waywardness to +which their whole nature compels them by their pressing need to +cultivate tactile sensations, to experiment, and to explore. +Therefore, much more commonly, the authority is exercised +intermittently and capriciously, with the result that the child's +judgment is clouded and confused. Conduct which is received +indulgently or even encouraged at one moment is sternly reprimanded at +another. Every one who has the management of little children must +above all see to it, whatever the degree of stringency in discipline +which they decide to adopt, that their attitude is always consistent. +The less that is forbidden the better, but when the line is drawn it +must be adhered to. If once the child learns that the force which +restrains him can be made to yield to his own efforts, the future is +black indeed. From that day he sets himself to strike down authority +with a success which encourages him to further efforts. I have known a +child of five years terrorise his mother and get his own way by the +threat, "I will go into one of my furies." + +The difficulty of successfully enforcing authority, and of carrying +off the victory if that authority is disputed, should make mothers +wary of drawing too tight a rein. The conflict between parent and +child must always be distressing and must always be prejudicial to the +child, whatever its outcome, whether it brings to him victory or +defeat. He learns from it either an undue sense of power or an undue +sense of helplessness, and the knowledge of neither is to his benefit. +Although frequently worsted in the conflict, nurses will often return +to the attack again and again and hour after hour, restraining, +reproving, forbidding, and even threatening. Nor do they see that they +are really goading the children into disobedience by their misdirected +efforts at enforcing discipline. Reproof, like punishment, loses all +its effect when it is too often repeated, and the child soon takes it +for granted that all he does is wrong, and that grown-up people exist +only to thwart his will, to misunderstand, to reprove, or even to +punish. + +In the nursery the word "naughty" is far too frequently heard. It is +naughty to do this, it is naughty to do that. There is no gradation in +the condemnation, and the child loses all sense of the meaning of the +word. He himself proclaims himself naughty almost with satisfaction: +his doll is naughty, the dog is naughty, his nurse and mother are +naughty, and so forth. In reality the little child is peculiarly +sensitive to blame, if he is not reproof-hardened. It is hardly +necessary to use words of blame at all. If he is asked kindly and +quietly to desist, much as we would address a grown-up person, and +does not, he can be made to feel that his conduct is unpopular by +keeping aloof from him a little, by disregarding him for the time +being, and by indicating to him that he is a troublesome little person +with whom we cannot be bothered. + +Any one who has had much to do with children will realise that, if +wrongly handled, they are apt to take a positive delight in doing what +they conceive to be wrong. There is clearly a delightful element of +excitement in the process of being naughty, of daring and of braving +the wrath to come, with which they are so familiar and for which they +care nothing at all. But the perverseness of which we are now speaking +has a different origin. It arises only when children are reproved, +appealed to, and expostulated with too often and too constantly. +Negativism is a symptom which is common enough in certain mental +disorders. The unhappy patient always does the opposite of what is +desired or expected of him. If he be asked to stand up he will +endeavour to remain seated, or if asked to sit he will attempt to rise +to his feet. Like many other symptoms of nervous disturbance which we +shall study later, this negativistic spirit is often displayed to +perfection by little children when the environment is at fault and +when grown-up people have too freely exercised authority. A mother, +anxious to induce her little son to come to the doctor, and knowing +well that her call to him to enter the room, as he stands hesitating +at the door, will at once determine his retreat to the nursery, has +been heard to say, "Run away, darling, we don't want _you_ here," with +the expected result that the docile child immediately comes forward. +To the doctor, that such a device should be practised almost as a +matter of course and that its success should be so confidently +anticipated, should give food for thought. It may shed light on much +that is to follow later in the interview. + +The question of punishment, like that of reproof, is beset with +difficulty. There are fortunately nowadays few educated mothers who +are so foolish as to threaten punishment which they obviously do not +intend to administer and which the child knows they will not +administer. It is clear that punishment must be rare or else the child +will grow habituated to it, and with little children we cannot be +brutal or push punishment to the point of extreme physical pain. It is +more difficult to say, as one is tempted to say, that all punishment +is futile and should be discarded. Probably mothers are like +schoolmasters in that no two schoolmasters and no two mothers obtain +their effects in exactly the same way or by precisely the same means. +Nor do all children accept reproof or submit to punishment in the same +way. Some make light of it and take a pleasure in defying authority. +Others are unduly cast down by the slightest adverse criticism. It is +generally true that extreme sensitiveness to reproof is a sign of a +certain elevation of character. Always we must remember that for a +mother to inflict punishment, whether by causing physical pain or +mental suffering, is to take on her shoulders a certain +responsibility. It is a serious matter if she has misapprehended the +child's act--if the sin was not really a sin, but only some perverted +action, the intention of which was not sinful, but designed for good +in the faulty reasoning of the child. A little girl, in bed with a +feverish cold, was found shivering, with her night-dress wet and +muddy. It was an understanding mother who found that her little +brother, having heard somehow that ice was good for fevered heads, had +brought in several handfuls of snow from the garden, not of the +cleanest, and had offered them to aid his sister's recovery. It need +hardly be said that punishment should always be deliberate. The hasty +slap is nothing else than the motor discharge provoked by the +irritability of the educator, and the child, who is a good observer on +such points, discerns the truth and measures the frailty of his judge. + +The frequent repetition of words of reproof and acts of punishment has +a further disadvantage that the older children are quick to practise +both upon their younger brothers and sisters. There is something wrong +in the nursery where the lives of the little ones are made a burden to +them by the constant repression of the older children. But although +set and artificial punishments are as a general rule to be used but +sparingly, the mother can see to it that the child learns by +experience that a foolish or careless act brings its own punishment. +If, for example, a child breaks his toy, or destroys its mechanism, +she need not be so quick in mending it that he does not learn the +obvious lesson. If the baby throws his doll from the perambulator, in +sheer joy at the experience of imparting motion to it, she need not +prevent him from learning the lesson that this involves also some +temporary separation from it. Throughout all his life he is to learn +that he cannot eat his cake and have it too. The use of rewards is +also beset with difficulties. Their coming must be unexpected and +occasional. They must never degenerate into bribes, to be bargained +for upon condition of good behaviour. Rewards which take the form of +special privileges are best. + +The æsthetic sense of children develops very early. From the very +beginning of the second year they take delight in new clothes, and in +personal adornment of all sorts. They show evident pleasure if the +nursery acquires a new picture or a new wall-paper. They have +pronounced favourites in colours. Even tiny children show dislike of +dirt and all unpleasant things. Personal cleanliness should be clearly +desired by all children. A sense of what is pleasant and what is +unpleasant should be encouraged. Any delay in its appearance is apt to +imply a backwardness in development of mind or of body. Only children +who are tired out by physical illness or by nervous exhaustion will +lie without protest in a dirty condition. + +Affection and the attempt to express affection appear clearly marked +even in the first year. Too much kissing and too much being kissed is +apt to spoil the spontaneity of the child's caresses. We must not, +however, expect to find any trace in the young child of such a complex +quality as unselfishness or self-abnegation. The child's conception of +his own self has but just emerged. It is his single impulse to develop +his own experience and his own powers, and his attitude for many +years is summed up in the phrase: "Me do it." We must not expect him +to resign his toys to the little visitor, or the little visitor to +cease from his efforts to obtain them. In all our dealings with +children we must know what we may legitimately expect from them, and +judge them by their own standards, not by those of adult life. We +cannot expect self-sacrifice in a child, and, after all, when we come +to think of it, obedience is but another name for self-sacrifice. If +the tiny child could possibly obey all the behests that are heaped +upon him in the course of a day by many a nurse and mother, he would +truly be living a life of complete self-abnegation. Surely it is +because the virtue of obedience, the virtue that is proclaimed +proverbially the child's own, is so impossible of attainment that it +is become the subject of so much emphasis. As Madame Montessori has +put it: "We ask for obedience and the child in turn asks for the +moon." Only when we have developed the child's reasoning powers, by +treating him as a rational being, can we expect him deliberately to +defer his wishes to ours, because he has learned that our requests are +generally reasonable. + + + + +CHAPTER III + +WANT OF APPETITE AND INDIGESTION + + +The mind of the child is so unstable and yet so highly developed, that +symptoms of nervous disturbance are more frequent and of greater +intensity than in later life. Only rarely and in exceptional cases do +certain symptoms, common in childhood, persist into adult life or +appear there for the first time, and then usually in persons who, if +they are not actually insane, are at least suffering from intense +nervous strain. We have already mentioned the symptom of negativism +and noted its occasional occurrence as an accompaniment of mental +disorder in adult life, and its frequency among children who are +irritable or irritated. Similarly, we may cite the digestive neuroses +of adult life to explain the common refusal of food and the common +nervous vomiting of the second year of life. Thus, for example, there +exists in adult life a disturbance of the nervous system which is +called "anorexia nervosa." A boy of nineteen was brought to the +Out-patient Department of Guy's Hospital suffering from this +complaint. He was little more than a skeleton, unable to stand, hardly +able to sit, and weighing only four and a half stones. His mother, +who came with him, stated that he had always been nervous, and that +lately, after receiving a call to join the army as a recruit, his +appetite, which had for some time been capricious, had completely +disappeared. In spite of coaxing he resolutely refused all food, or +took it only in the tiniest morsels, although at the same time it was +thought that he sometimes took food "on the sly." A careful +examination showed absolutely no sign of bodily disease. He was +admitted to a ward for treatment by hypnotic suggestion, but before +this could be begun he endeavoured to commit suicide by setting fire +to his bed. + +A girl of twenty-four years of age had become almost equally +emaciated. Constant vomiting had persisted for many years and had +defied many attempts at cure. It had even been proposed to perform the +operation of gastro-enterostomy in the belief that some organic +disease existed. In suitable surroundings and with the energetic +support of a good nurse, who spent much time and care in restoring her +balance of mind, the vomiting ceased, and she gained over two stones +in weight. Work was found for her in some occupation connected with +the War, and she left the Nursing Home to undertake this, bearing with +her four pounds which she had abstracted from the purse of another +patient. + +Those who have not opportunities of observing how all-powerful is the +effect of the mind upon the body, and especially perhaps upon the +process of digestion, may find it hard to believe that these +distressing symptoms and profound changes in the aspect and nutrition +of the patients were due entirely to mental causes and were symptoms +in accord with the attempted suicide or the theft of the money. In +nervous little children we shall not often find such complex actions +as suicide or theft, although they do occur, but combined with other +evidence of nervousness we shall meet commonly enough with a +persistent setting aside of appetite and refusal of food and with +continuous and habitual vomiting, from nervous causes. + +The experiments of Pawlow and others have explained the dependence of +digestion upon mental states. They show that even before the food is +taken into the mouth, while the meal is still in prospect, there has +been instituted a series of changes in the wall of the stomach, which +gives rise to the so-called psychic secretion of gastric juice. These +changes are preceded by the sensation of appetite, which is evoked not +by the presence of food in the stomach--for the food has not yet been +swallowed--but by the anticipation of it, by the sight and smell of +food, as well as by more complex suggestions, such as the time of day, +the habitual hour, the approach of home, and so forth. + +Emotional states of all sorts--grief, anger, anxiety, or +excitement--put a stop to the process or interfere with its action, so +that the sense of appetite is absent, and the taking of food is apt to +be followed by discomfort or pain or vomiting. No doubt good digestion +leads to a placid mind, but it is equally true that a placid mind is +necessary for good digestion. Therefore we civilised people, living +lives of mental stress and strain, try to increase the suggestive +force of our surroundings and to provoke appetite by all devices +calculated to stimulate the æsthetic sense. The dinner hour is fixed +at a time when all work and, let us hope, all worry is at an end for +the day. The dinner-table is made as pretty as possible, with flowers +and sparkling glass. We are wise to dress for dinner, that with our +working clothes we may put off our working thoughts. + +In the treatment of adult dyspepsia we seldom succeed unless we can +place the mind at rest. We may advise a visit to the dentist and a set +of false teeth, or we may administer a variety of stomach tonics and +sedatives, but if the mind remains filled with nameless fears and +anxieties we shall not succeed. + +In adult life the nervous person when subjected to excessive stress +and strain is seldom free from dyspeptic symptoms of one sort or +another, and what is true of adult life is even more true of +childhood, when the emotions are more poignant and less controlled. +Then tears flow more readily than in later life, and tears are not the +only secretions which lie under the influence of strong emotion. +Emotional states, which would stamp a grown man as a profound +neurotic, are almost the rule in infancy and childhood, and may be +marked by the same physical disturbances--flushing, sweating, or +pallor, by the discharge of internal glandular secretions as well as +by inhibition of appetite, by vomiting, gastric discomfort, or +diarrhoea. Naturally enough, mothers and nurses are wont to demand a +concrete cause for the constant crying of a little child, and +teething, constipation, the painful passage of water, pain in the +head, or colic and indigestion are suggested in turn, and powders, +purges, or circumcision demanded. There can be no doubt that nervous +unrest is capable of producing prolonged dyspepsia in infancy and +childhood--a dyspepsia which, while it obstinately resists all +attempts to overcome it by manipulation of the diet, is very readily +amenable to treatment directed to quiet the nervous system. + +Where a primary dyspepsia exists for any length of time, the growth +and the nutrition of the child is clearly altered for the worse. The +character of the stools, their consistency, smell, and colour, is apt +to be changed because the bacterial context of the bowel has become +abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, +prolapse of the rectum, and infection with thread-worms are common +complications. No doubt children with primary dyspepsia are often +nervous and restless, and the elements of infection and of neurosis +are frequently combined. Yet often we meet with cases in which the +gastric or intestinal disturbance comes near to being a pure neurosis. +The nutrition, then, seldom suffers to any very great extent, or to a +degree in any way comparable to that which is characteristic of +dyspepsia from other causes. Emaciation, wrinkling of the skin, +dryness and falling out of the hair, decay of the teeth, are not as a +rule part of the picture of nervous dyspepsia. The child may be slim +and thin and nervous looking, but as a rule he is active enough, with +a good colour and fair muscular tone, so that one has difficulty in +believing the mother's statements, which are yet true enough, as to +the trouble which is experienced in forcing him to eat, or as to the +frequency of vomiting. + +In early childhood the difficulty of the refusal of food often passes +or diminishes when the child learns to feed himself with precision and +certainty. To teach him to do so, it is not wise to devote all our +attention to making him adept at this particular task. The fault is +that the brain centres which control the movements of hands, mouth, +and tongue have not been developed, because his activities in all +directions have not been encouraged. It is much less trouble for a +nurse to feed a little child than to teach him to feed himself, and if +he is not given daily opportunities of practice he will certainly not +learn this particular action. But the fault as a rule lies deeper. The +child who cannot feed himself cannot be taught until fingers and brain +have been developed in the thousand activities of his daily routine, +by which he acquires general dexterity. A child who is still too young +to feed himself is learning the dexterity which is necessary as a +preliminary in every action of the day. If he can carry the tablecloth +and the cups and saucers to the tea-table, imitating in everything the +action of his nurse, it will be strange if he does not also imitate +her in the central scene, the actual eating of the food. If, on the +other hand, he is waited upon hand and foot, if he is restrained and +confined, sitting too much passively, now in his perambulator, now in +his high chair, now on his nurse's lap, his imitative faculties and +his tactile dexterity alike remain undeveloped. The child who is slow +in learning to feed himself shows his backward development in every +movement of his body. One may note especially the stiff, +"expressionless" hands, indicating a general neuro-muscular defect. I +have seen many children of eighteen months or two years of age in whom +the movements necessary for efficient mastication and swallowing had +failed to develop satisfactorily. In some a pure sucking movement +persisted, so that when, for example, a morsel of bread or rusk was +put in the child's mouth, it would be held there for many minutes and +submitted only to suction with cheeks and tongue. Attempts to swallow +in such a case are so incoordinate that they give rise frequently to +violent fits of choking, which distress the child and produce +resistance and struggling, while at the same time they alarm the +mother or nurse so much that further attempts to encourage the taking +of solid food are hastily and for a long time abandoned. In this +helpless condition the other factors which tend to develop what we +have called negativism have full play. The want of imitation and the +lack of dexterity is not the sole or perhaps the main cause of the +child's refusal of food and of the apparent want of appetite, but it +is the cause of the failure to learn to feed himself, which places +him in a condition which is peculiarly favourable to the operation of +other factors. If only we can teach the child to feed himself, the +difficulties of the situation become much less formidable. + +The first of the factors which encourage the persistent refusal of +food is the extreme susceptibility of the child to suggestion. A +particular article of diet may be refused on one occasion, perhaps in +pique, because another more favoured dish was hoped for or expected, +or perhaps because the taste is not yet familiar. Then if on this +occasion a struggle for the mastery is waged, and a painful impression +is made on the child's mind connecting this particular dish with +struggling and tears, from that day forward the child may persistently +refuse it on every occasion it is offered. Matters are made worse if +the nurse, anticipating refusal, attempts to overcome the resistance +by peremptory orders, or by excessive praise extolling the delicious +flavour with such fervour that the child's suspicions are at once +aroused. Previous experience has made him connect these excessive +praises with articles which have aroused his distaste. If these fads +and fancies on the part of the child are to be avoided, it is +essential that we should do nothing to focus his attention on his +refusal. It is better that his dinner should be curtailed on one +occasion than that taste and appetite should be perverted perhaps for +years. Every nurse or mother should cultivate an off-hand, detached +manner of feeding the child, and should patiently continue to offer +the food without uncalled-for comments or exhortations. Let her always +remember the force of suggestion on the child's mind, and that a +confident manner which never questions the child's acceptance will +meet with acceptance, while a hesitating address, from fear of the +impending refusal, will be apt to meet with refusal. Sometimes a still +worse fault manifests itself, when nurse and mother speak before the +child of the smallness of his appetite, and of his persistent refusal +of this or that article of diet. The suggestion then acts still more +powerfully on his mind. He is aware that the whole household is +distressed by his peculiarity, and he grows to identify it with his +own individuality, and to regard himself with some satisfaction as +possessing this mark of distinction. If there is any difficulty of +this sort it is often directly curative to reverse the suggestion and +to speak before him of his improving appetite, and to say that he +begins every day to eat better and better, even if to do so we have to +break a good rule never to say to the child what is not strictly true. +Or once or twice we may take his plate away before he has finished, +saying positively that he has eaten so much that he must eat no more. +If in spite of every care antipathies to certain articles of food +appear and persist, we must be content to bide our time. When the +child grows of an age to reason, we should seize every opportunity to +make him feel that his persistent refusal is a little ridiculous and +childish. Little by little the seed is sown, and will germinate till +one day we shall note with surprise that he has taken of his own +accord that which he has neglected for so long and with such +obstinacy. + +But the force which is acting most strongly in producing this refusal +of food is the force of which we have spoken in a previous +chapter--the force which results in negativism, the force which is in +reality the habit of opposition, the love of power, and the desire to +attract attention. Here again the refusal of food, if due to this +cause, is never the sole manifestation of the fault. Just as the delay +in learning to swallow and to chew properly and to feed himself is +part of a general want of dexterity and capacity manifested in all his +actions, so it will seldom happen that the child's anxiety to oppose +is only seen at meal-times. Watch a nervous child in the nursery +before the dinner hour. He is cross and restless and inclined to cry. +The nurse hands him a doll, and he throws it away saying, "No, no +doll." At the same moment he may catch sight of his ball, and it too +is violently rejected, "No, no ball." Everything in turn is treated in +the same way. Finally he falls upon his nurse, crying and beating her +with his hands, saying, "No, no Nurse." If that long-suffering woman +at that moment summons him to dinner, it will be strange indeed if his +attitude is not "No, no dinner," and "No, no" to every mouthful +offered him. How strong this love of opposition may be is illustrated +by the case of a little boy who was brought to me for refusal of food. +Three weeks before, he had been taken in a motor-car to his +grandfather's to midday dinner on Sunday, when his absolute refusal of +food had spoiled the day and had occupied the attention and the +efforts of the whole party. Doubtless he had enjoyed himself, for +three weeks later, when he caught sight of the car which was to bring +him to me, and which he had not seen in the interval, he at once said, +"Not eat my dinner." This child's father told me that the sight or +sound of the preparation of a meal was enough to bring on a paroxysm +of opposition. Now this force of opposition, as we have seen, only +develops into a serious difficulty when the child's own will has been +opposed too much, when authority has been too freely exercised, and +when the child has been urged and entreated and reproved with too +great frequency. His opposition grows with all counter-opposition. And +he is not really naughty, only irritable and restless from the +thwarting of his natural impulses, and unable to express his thoughts +and desires. Negativism will not often confine itself to meal-times. +It will show clearly in all the actions of the child, and to get him +to eat well and freely we must so change our management of him that +negativism disappears or at least diminishes. There is no other way. +No entreaty, no force, no threats of force will ever succeed, but will +only make him worse, and, since negativism is due to mental unrest, +the struggles and crying will only perpetuate the cause. The one way +to banish negativism and overcome the opposition is to cease to +oppose, and to practise this aloofness not so much at meal-times, for +somehow by patience the child must be got to take his food, but in all +our conduct to him. Repression and reproof, and thwarting of the +child's will, and coaxing and entreaty must cease. There is no fear +that we shall thereby make the child unduly disobedient. We have +already, in another chapter, decided that negativism is not strength +of will on the part of the child which must be broken, but is the +result of constant attempts to oppose his nature, and the consequent +nervous unrest. If we cease to oppose, the symptoms will tend rapidly +to disappear, the child will become busy and contented and happy in +his play, and we shall hear no more of his refusal of food. If +sometimes it recurs for a week or two, we shall know how to deal with +it. + +In children, as with us, periods of nervous unrest and unhappiness are +apt to recur in a sort of cycle. This cyclical character of mental +disturbance is often a marked feature. We see it in epilepsy and +in what the French have called Folie Circulaire. We see it in the +dipsomaniac, in the intermittency of his craving for drink and of his +periodical outbursts, and we see it in ourselves in those periods of +depression which recur so often, we know not why. Little children too +sometimes get out on the wrong side of their beds, and never get right +the whole long day. Their own experience of the vagaries of mental +states should lead mothers to be indulgent to the children in their +days of cloud and to be particularly careful not to goad them by +well-intentioned efforts into bursts of naughtiness and passion, each +one of which tends to perpetuate the condition and increase the +nervous unrest. We know how closely dependent is the sensation of +appetite upon emotional states, and we must do all in our power--and +the task is sometimes one of real difficulty--to keep the child's mind +sufficiently at rest to preserve the healthy desire for food +unimpaired. If there is no sign of appetite, but every sign of +restlessness and irritability, we must seek in the management of the +child until we find the fault. + +If food is taken mechanically and without appetite, if the preliminary +changes in the stomach wall which are necessary for adequate digestion +do not take place, but are inhibited by the mental unrest, the meal is +apt to be followed by gastric pain and discomfort, or, more commonly +with children, the stomach may promptly reject its contents. At the +worst, nervous vomiting of this sort may follow almost every meal, +although, again, it is curious to note how little, comparatively +speaking, the nutrition of the child suffers. The vomiting too, as in +adults, comes very near being a voluntary act, and mothers and nurses +will often remark that they get the impression that it can be +controlled at will. If once the diagnosis is made that the want of +appetite or the vomiting is of nervous origin, the treatment of the +condition is clear. Sedative drugs directed towards quieting the +nervous excitability may be of service, but tonics, appetisers, +laxatives, and drugs with a direct action on the stomach will have but +little effect. Nor is there as a rule anything to be gained by +modifying the diet or by excluding this or that article of food. The +frequency of the vomiting is such that it is apt to have brought +discredit one after the other upon almost every article of food which +the child can take, with the result that many useful and necessary +foods have been abandoned for long on the ground that they are the +cause of the dyspepsia. A permanent cure will only be effected when +the faults of environment have been overcome, when the cause of the +nervous unrest has been removed, and when the child's mind is at +peace. + +Nervous vomiting of this kind is not difficult to control, if those in +charge of the children can be made to understand that the cause lies +in the anxiety which they themselves show before the child, increasing +his own apprehension or adding to his sense of power or importance. +Once the child is convinced that his conduct excites no particular +interest, the vomiting soon ceases. In more than one instance, +vomiting which has persisted for many months has stopped at once after +the matter has been fully explained to the parents. In the most +inveterate case of this sort which has come under my notice, the child +was regularly sick as soon as he caught sight of a white cloth being +laid on the table for meals. Yet even this child never vomited when he +was under the charge of a particular nurse who had to return more than +once to the family, and on each occasion was successful in breaking +the habit. + + + + +CHAPTER IV + +WANT OF SLEEP + + +So far, almost all that has been written--and there has been a great +deal of unavoidable repetition--has been devoted to an attempt to +determine the causes which lead the child to refuse food and the +methods which we adopt to prevent or overcome the difficulty. Other +neuroses may be studied in less detail, because they depend for their +existence upon the same causes. For example, the habit of refusing +sleep, which is as common and almost as distressing as the habit of +refusing food, depends both upon a perversion of suggestion and upon +the phenomenon that we have called negativism. + +If struggling and crying has occurred upon a series of nights, the +child comes to associate his bed not with sleep but with tears. If a +mother values her peace of mind, if she would spare herself the +discomfort of hearing her child sob himself nightly into uneasy sleep, +she must be wary how this all-important event of going to bed is +approached. With a nervous and restless child the preliminaries of +preparing for bed must be managed carefully and tactfully. The hour +before bedtime is almost universally the most interesting of the +whole day for the child. Then the baby, with his best frock on, and +books and toys, is the centre of interest in the drawing-room, till +the clock strikes and the nurse appears at the door. Suddenly it is +all over, and inexorable routine sends him off to bed. The good nurse +will give the child a little time to recover from the shock of her +arrival, and will not hurry him. She knows that his little mind is +slow to act, and that he must be led gradually to face a new prospect. +If she hurries him, catching him up in her arms from the midst of his +unfinished pursuits, resistance and tears are almost sure to follow, +and the difficult task of the day--the putting to bed--has made the +worst possible start. When this has happened on one or two successive +evenings, the habit of resistance to going to bed becomes fixed, and, +like all bad habits, is difficult to break. A nurse who has a way with +children will arouse his interest in a new pursuit, in which he can +play the chief part, the putting away of his picture books and toys. +If he is too small to carry his own chair or table to its allotted +place in the room, at least he can show his learning by pointing out +the spot. In the waving of good-byes he is expert and takes a +legitimate pride, and upstairs he has learnt that there are new +delights. He himself can turn on the taps in the bathroom, and he can +set every article in the proper place ready for use. All children love +their bath, and if interest and good temper has been so far preserved, +without a break, it will be ill-fortune if even the drying process is +not carried off without a hitch. Afterwards, for a little, nervous +babies, whose brains still teem with all the excitements of the day, +are best left to sit for a few moments by the nursery fire, while the +nurse puts all the garments one by one to bed. Each as it goes to rest +will be greeted by him with cheerful farewells; and so does the force +of suggestion act, till the central figure himself plays his part in +the scene, of which he feels himself the controller and director, and +climbs to bed. But if there has been a hitch anywhere, if the bugbear +of negativism has appeared, if he has been scolded or coaxed or +repressed too much and there have been tears and struggles, then going +to bed is a poor preparation for instant and quiet sleep. + +With excitable, highly-strung children, the best laid plans and the +most tactful nurse will not always succeed, and to place him in his +cot is to provoke a storm of angry refusal and resistance. There are +mothers who believe that the best way is then to turn out the light +and leave the child to cry himself to sleep. This is a point on which +no one can lay down rules which are applicable for all children. It +may sometimes succeed, and the child may reason correctly and in the +way we wish him to reason, deciding that the game is not worth the +candle and so give it up. But with nervous, highly-strung children I +doubt if this Spartan conduct is commonly successful. Often if the +attempt is made, the troubled mother, listening to all these +heart-breaking sobs, can bear it no longer, and goes back to the side +of the cot to soothe and persuade him. Then certainly the longer she +has restrained her natural inclination, the longer the child has +sobbed himself into a pitiful little ball of perspiration and tears, +the more difficult will be her task in quieting him, the stronger will +be the impression formed on the child's mind, and the greater will be +the suggestion which will act under the same circumstances to-morrow. +Children who fall a prey to this uncontrolled crying, cry on because +they cannot stop when they have begun. They do not then cry purposely +or with a fixed intention, desiring to attain some object. They cry +because their minds are not at rest, but are irritated and overwrought +by the happenings of the day. We decided that it was useless to +attempt by exhortations at meal-times to induce a nervous child to eat +who habitually refuses food, and that we can only cure the condition +by eliminating from his daily life the elements of repression and +opposition which provoke the counter-opposition. And we must seek the +same solution in this other difficulty of the refusal of sleep. It is +useless to attempt to treat the symptom of refusal of sleep and to +leave the cause of that symptom still constantly in action. + +If, in spite of our care to avoid unrest and irritation of the child's +brain, sleep is refused, as may often happen, it is, as a rule, wise +to cut short the crying if we can, before a vicious circle has been +formed and the unrest has been intensified by the emotional storm. It +is useless with little children to urge them to go to sleep or to +coax. It is not usually wise to leave the child for a little and then +to return. Each time the child is left, each time the mother or nurse +returns, the crying bursts forth again with renewed force and vigour. +It is at least one good plan with a little child to turn the light +out, and, treating the whole incident in the most matter-of-fact way +possible, lightly to stroke his head or pat his back rhythmically +without speaking. With older children, if the crying is more +purposeful and less emotional, the mother may busy herself for a +little with some task in the room, ostentatiously neglecting the storm +and making no reference to it. If she speaks to the child at all she +should do so in a matter-of-fact way, referring lightly to other +matters. If only she can convince him that his conduct is a matter of +indifference to her, the victory is won. It is because the child knows +so well that his mother does care that he so often has the upper hand. +It is not difficult to distinguish between a true emotional storm and +the tyrannous cry of a wilful child who demands his own way. + +Light and broken sleep is a common accompaniment of a too excitable +and overstimulated brain. The placid child, who eats well, plays +quietly, and does not cry more than is usual, as a rule sleeps so +soundly that no ordinary sounds, such as conversation carried on in +quiet tones in his neighbourhood, have the power to waken him. When he +wakes, he does so gradually, perhaps yawning and stretching himself. +The nervous child may move at the slightest sound, or with a sudden +start or cry is wide awake at once. A hard mattress should be chosen +without a bolster, and with only a low pillow. Flannel pyjamas, which +cannot be thrown off in the restless movements of the child, should be +worn. The temperature of the room should be cool, and the air from the +open window should circulate freely, while draughts may be kept from +striking on the child by a screen. All the sensations of the nervous +child are abnormally acute. Thus, for example, an itching eruption, or +tight clothing, will produce an altogether disproportionate reaction, +and may result in a frenzy of opposition. Especially such a child is +sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool +rooms and warm but light and porous clothing are essential. An +electric torch, which can be flashed on the child for an instant, will +assist the mother or nurse to make sure that the child has not thrown +off all the bedclothing. + +Sometimes want of sleep is accounted for by a real want of physical +exercise. Town children especially are apt to suffer from their +limited opportunities of running freely in the open. It is often +considered enough that the child seated in his perambulator should +take the air for three or four hours daily, while much of his time +indoors as well is devoted to sitting. It is necessary for his proper +development that he should have opportunities of daily exercise in the +open. If for any reason this is not always practicable, a large room, +as free as possible from furniture, should be chosen, with windows +thrown wide open, in which the child may romp until he is tired. + +It is rare for children of two or of three years of age, whose case +we are now considering, to be troubled by bad dreams, nightmares, or +night-terrors. If these should occur, obstructed breathing due to +adenoid vegetations is sometimes at work as a contributory cause. + +Finally, we should always remember that refusal of sleep is, for the +most part, caused and kept up by harmful suggestions derived from +mother and nurse, who allow the child to perceive their distress and +agitation, who speak before the child of his habitual wakefulness, who +unwittingly focus his attention on the difficulty. It is cured in the +moment that the suggestion in the child's mind is reversed, in the +moment when he comes to regard it as characteristic of himself not to +make a fuss about going to bed, but to sleep with extraordinary +readiness and soundness. Let every one join together to produce this +effect. Let the suggestion act strongly on his mind that all these +troubles of sleeplessness are diminishing, that night after night sees +an improvement, and soon his reputation as a good sleeper will be +established, and, as always with children, it will be rigidly adhered +to. + +In assisting to break the habit of sleeplessness, and in the process +of altering the character of the suggestions which act on the child's +mind, we can be of the greatest assistance to the mother by +prescribing a suitable hypnotic. As to whether it is right in insomnia +in childhood to prescribe depressant drugs is a question on which very +various opinions are held. That it is wrong and probably ineffective +to trust entirely to the drugs is certainly true, but as a temporary +measure, to break the faulty suggestion and the bad habit, their use +is both legitimate and successful. The dose required in children +relatively to the adult is much smaller. In grown people, some +specific distress of mind, whether real or imaginary, may suffice to +resist very large doses of hypnotic. In children it is rare to find +the same resistance, and comparatively small doses have a very +constant effect. With deeper and more refreshing sleep, the conduct of +the child during the day almost always changes for the better. A sound +sleep, for a few nights in succession, will produce apparently quite a +remarkable change in the whole disposition of the child. When good +temper and interest take the place of fretfulness and restlessness, we +may confidently expect that the symptom of sleeplessness will begin to +abate. Sleeplessness by night and fretfulness by day form a vicious +circle, and attempts must be made to break it at all points. + +Chloral occupies the first place as a hypnotic for young children. In +combination with bromide its effects are wonderfully constant and +certain. Two grains of chloral hydrate and two grains of potassium +bromide with ten minims of syrup of orange, given just before bedtime, +will bring sound sleep to a child of a year old. At three years the +dose may be twice as great, and three times at six years. It is seldom +that other means are required. Aspirin for children seems relatively +without effect. For children who are both sleepless and feverish, a +grain of Dover's powder, and a grain of antipyrin, for each year of +the child's age up to three, is very helpful. Lastly, if chloral and +bromide cannot break the insomnia, and the condition of the child is +becoming distressing, we can almost always succeed if we combine the +prescription with an ordinary hot pack for twenty minutes. + + + + +CHAPTER V + +SOME OTHER SIGNS OF NERVOUSNESS + + +HABIT SPASM + +Next to refusal of food and refusal of sleep perhaps the most frequent +manifestation of nervous unrest is provided by the group of symptoms +which we may call, with a certain latitude of expression, Habit +Spasms. By a habit spasm is meant the constant repetition of an action +which was originally designed to produce some one definite result, but +which has become involuntary, habitual, and separated from its +original meaning. The nervous cough forms a good example of a habit +spasm. A cough may lose its purpose and persist only as a bad habit, +especially in moments of nervousness, as in talking to strangers, in +entering a room, or at the moment of saying "How do you do" or +"Good-bye." Twitching the mouth, swallowing, elongating the upper lip, +biting the lips, wrinkling the forehead so strongly that the whole +scalp may be put into movement, and blepharospasm are all common +tricks of little children which may become habitual and uncontrolled. +In worse cases there may be constant jerking movements of the head, +nodding movements, or even bowing salaam-like movements. In mild +cases we may note hardly more than a restless movement of mouth or +forehead, or constant plucking or writhing of the fingers whenever the +child's attention is aroused, when he is spoken to, or when he himself +speaks. In nervous children these movements, which should properly be +confined to moments of real emotional stress, become habitual, and are +displayed apart from the excitement of particular emotions. Whatever +their intensity, habitual and involuntary movements of this nature +should not be overlooked, and should be regarded as evidence of mental +unrest. They do not commonly appear during the first or second years +of the child's life. They are more frequent after the age of five, but +they may begin to be marked as early as the third year. With refusal +of food and refusal of sleep they form the three common neuroses of +early childhood. + +Two of the three qualities which we have mentioned as characteristic +of the child's mind are concerned in the causation of habit spasm. In +the early stages the movement is sometimes due to imitation, but the +susceptibility of the child to suggestion plays the chief part in +determining its persistence. It is an interesting speculation how far +tricks of gesture, attitude, or gait are inherited and how far they +are acquired by imitation. A child by some characteristic gesture may +strikingly call to mind a parent who died in his infancy. A whole +family may show a peculiarity of gait which is at once recognisable. +It is told of the son of a famous man, who shared with his father the +distinctive family gait, that when a boy his ears were once boxed by +an old gentleman who chanced to observe him hurrying to overtake his +parent, and who resented what he took to be an act of impertinent +caricature. In the reproduction by the child of the habitual actions +of his parents, heredity is largely concerned, but imitation too plays +its part. In habit spasm the force of imitation is clearly seen. A +child who has developed a habit spasm of one sort or another will +readily serve as a model to other children. The malady will sometimes +spread through a school almost with the force of a contagious +disorder. A child affected in this way may prove an unwelcome guest. +The little visitor with a trick of contorting his mouth and grimacing +is apt to leave his small host an expert in faithfully reproducing the +action. A cough that is genuine enough in one member of the family may +produce a crop of counterfeits in brothers and sisters. + +The force of suggestion acting upon the child's mind can clearly be +traced. Once his attention is focused upon the particular movement by +unwise emphasis on the part of the parents, he loses the power to +control its occurrence. This trio of common neuroses--refusal of food, +refusal of sleep, and habitual involuntary movement--grows only in an +atmosphere of unrest and apprehension. Parents and nurses anxiously +watch their development. They are distressed beyond measure to note +their steady growth in spite of every attempt which they make to +control or forbid them. And of all this unrest and unhappiness the +child is acutely conscious. The whole household may become obsessed +with the misfortune which has befallen it, and the mother, losing all +sense of proportion, feels that she cannot regain her peace of mind +until it has been overcome. The child is in need of mental and moral +support from those around him, and all that he finds is an openly +expressed apprehension and sense of impotence. Even grown-up people, +when their nerves are on edge, are apt to be obsessed by +uncontrollable impulses or by vague and nameless apprehensions, and +surely all have learnt the support they gain from contact and +conversation with some one strong and sane, who treats their worries +in such a matter-of-fact way that immediately they lose their power +and become of no account. The child with habit spasm cannot control +these movements. The more he is reproved or entreated, the less able +does he find himself to hold them in check. He does not wish them to +continue. He has lost control of what he once controlled, and the +realisation of this is not pleasant, and may be alarming to him. Yet +when unconsciously he looks to his mother for support, he finds in her +open dismay that which serves only to increase his uneasiness. She +must subdue her own feelings and give the child strength. If she +treats the whole thing in a matter-of-fact way, as a temporary +disturbance which is of no importance in itself, and only has meaning +because it implies that the brain has been over-stimulated, she will +no longer exercise a prejudicial effect on the child. If the bad habit +is taken as a matter of course, if too much is not made of it, if the +child is encouraged to think that nobody cares much about it at all, +then recovery will soon take place. It goes without saying that habit +spasms and tics of all sorts are made worse by excessive emotional +display and by nervous fatigue. On the other hand, if the child +becomes absorbed in some interesting occupation, the movements will +disappear for the time being. + + +AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING + +At a somewhat earlier age than that in which habit spasms become +common, and before bed wetting appears as a formidable difficulty, we +meet with another group of habitual actions which yet retain their +voluntary character. Among such habitual actions are thumb sucking, +thigh rubbing, and air swallowing. If the child is old enough to +express himself on the subject, he will explain that these actions are +performed because of the satisfaction derived from them, because it is +"comfy" and "nice." Even if the child is too small to speak, the +expression is that of beatitude and content. These actions are not +confined to nervous children, and their occasional practice need not +be taken to imply that there is any strong element of nervous +overstrain. It is only when the action is repeated with great +frequency and persistence, and when signs of irritation ensue if +gratification is not obtained, that we are justified in classing it +among the symptoms of mental unrest. + +The second of these actions, thigh rubbing, is found for the most +part in little girls, and inasmuch as it consists of a stimulation of +the sexual organs sometimes causes much distress to the parents. It is +in reality a habit of small importance unless exercised with very +great frequency. It is, of course, not associated in the child's mind +with any sexual ideas, and is of precisely the same significance as +the other two actions of the same class. Children who can speak will +refer to it openly without any sense of shame. As a rule the action is +performed in a half-dream state, that condition between sleeping and +waking which is found when the child is lying in the morning in her +cot or in her perambulator after the midday nap. The child's attention +should not be focused on the symptom. She should lie on a hard +mattress, and when she wakes in the morning she should either leave +her cot at once or she should be roused into complete wakefulness by +encouraging her to play with her toys. Little children should be +taught to sleep with their hands folded and placed beside the cheek. +If the movement occurs on going to sleep, it is best left alone and +completely neglected. As a rule each child has his or her own +favourite action of this class, and they are seldom combined in the +same child. If thigh rubbing is very constant and obstinate and does +not yield to the measures suggested, it may even sometimes be a +successful manoeuvre to substitute the thumb-sucking habit in the +expectation that this less distressing habit may eject the other more +objectionable action. As a rule, however, a wise neglect and careful +watching during the drowsy condition that follows sleep in a warm bed +will succeed in stopping the practice of thigh rubbing before the end +of the second or third year. Apparatus designed to restrain movement +of the child's legs or blistering the opposed surfaces of the thighs +are both of no effect. They have indeed the positive disadvantage that +they focus the child's attention on the practice. The habit ceases +only when the child has forgotten all about it, and these devices +serve only to keep it in remembrance. The same may be said of any +system of punishments. Further, we cannot always have the child under +observation, and at some time or other opportunity will be found for +gratification. Of older children, in whom self-control and a sense of +honour can be cultivated, I am not here speaking. + +Air swallowing is less common than thigh rubbing, but belongs to the +same group of actions and takes place in the same drowsy condition. +The child will rapidly gulp down air which distends the stomach, and +is then regurgitated with a loud sound. Thumb sucking seldom +distresses the mother to the same extent, and the proper attitude of +tolerance is adopted towards it. If much is made of it, it is +astonishing how persistent the habit may become, surviving all +attempts to forbid it, to break it by rewards or punishments, or to +render it distasteful by the application of a variety of ill-tasting +substances smeared on the offending digit. + +PICA AND DIRT EATING + +Certain other bad habits will become ingrained if attention is called +to them, because of that curious spirit of opposition which +characterises little children, and because of their susceptibility to +suggestion. Some children will constantly pluck out hairs and eat +them, or will devour particles of fluff drawn from the blankets. +Others will seize every opportunity to eat unpleasant things, such as +earth, sand, mud, or dirt of any sort. All tricks of this sort are +best neglected and treated by attracting the child's attention to +other things. In adult life they are associated with serious mental +disturbance, in early childhood they are of little account, or at most +suggest a certain nervousness which may be due to nervous irritation +from faults of management which we must strive to correct. + + +CONSTIPATION + +As has been already mentioned, much of the common constipation of the +nursery is due to neurosis. The excessive concentration of the nurse's +thoughts on this daily question communicates itself to the child. The +difficulty is emphasised, and an attempt is made to substitute will +power for forces of suggestion which are at once inhibited by +concentration of the mind upon the process. Here also, just as in the +refusal of food, a further stage of "negativism," that is, of active +resistance with crying and struggling, is reached, so that complaint +may be made by the mother that defæcation is painful. The same +negativism may be shown in micturition, and mothers will give +distressing accounts of the suffering of the child during the passing +of water. + + +BREATH-HOLDING AND LARYNGISMUS STRIDULUS + +In some children, in the first two years of life, we find a definite +and measurable increase in the irritability and conductivity of the +peripheral nerves. The strength of current necessary to produce by +direct stimulation of the nerve a minimal twitch of the corresponding +muscle may be many times less than the normal. Of this heightened +irritability of the nervous system, to which the name "spasmophilia" +has been given in America and on the Continent, the most striking +symptom is a liability alike to tetany or carpo-pedal spasm, to +generalised convulsions, and to laryngismus stridulus. In addition, in +most cases it is generally possible to demonstrate the presence of +Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a +visible twitch of the facial musculature, especially of the +orbicularis palpebrarum or of the orbicularis oris, in response to a +gentle tap administered over the facial nerve in front of the ear. +Trousseau's sign is the production of tetany by applying firm and +prolonged pressure to the brachial nerve in the upper arm. The +ætiology of spasmophilia is still a matter for dispute, but the +evidence which we possess is in favour of the view that we have here +to deal with a disturbance of calcium metabolism. The calcium content +both of the blood and of the central nervous system has been shown to +be much lowered. It is in keeping with this that clinically we note +how frequently spasmophilia and rickets occur in the same child. In +some families the condition recurs through many generations. + +For our present purpose--the examination of some common neuroses of +nursery life--it would be out of place to enter into a detailed +consideration of this disorder of spasmophilia as a whole. The symptom +of laryngismus stridulus--the so-called breath-holding--alone need +concern us, and that for a special reason. The spasm of the glottis is +produced under the influence of any strong emotion--in anger, for +example, or in fear, in excitement or in crying for any reason. To +control or prevent it we must direct attention not only to the +condition of spasmophilia, but also to the management of the children +who are always excitable and emotional. In these children every burst +of crying, however produced, whether by a fall, by a fright, by the +entrance of a stranger, or by a visit to a doctor, is apt to be +ushered in by a long period of apnoea, due to spasm of the glottis +and of the diaphragm. The first few expirations are not followed by +any inspiration. For several seconds the silence may be complete, +while the child steadily becomes more and more cyanosed, or the body +may be shaken by incomplete expiratory movements and strangled cries +which are suppressed because the chest is already in a position of +almost complete expiration. In the worst cases, when the apnoea +lasts a very long time, there may be convulsive twitching of the +muscles of the face, or the attack may even terminate in general +convulsions. Very occasionally the spasm is actually fatal. In all +fatal cases which have come to my notice the child at the moment of +death had been alone in the room. I have met with no fatal case where +the baby could be picked up and assisted. As a rule, therefore, the +cause and mode of death must be conjectural, but when an infant is +found dead in its cot unexpectedly, it would seem likely that it has +waked from sleep with a sudden start, become excited, and, about to +cry, has been seized by the fatal spasm. In two instances reported to +me a cat had been found in the room with the dead child, and it was +suggested that the animal had lain upon the child's face. Both these +children, however, were vigorous and capable of powerful movements of +resistance. I think it more likely that the cat may have awakened them +in fright, and that the emotional excitement, giving rise to the +spasm, was the cause of the suffocation. That the apnoea in these +extremely rare instances should end fatally produces a difficult +position for the doctor. It need hardly be said that the seizures are +alarming to the parents. For the sake of great accuracy in the +statement of our prognosis are we to add a hundred times to the +mother's alarm by stating the possibility of death? In each case we +must use our own judgment. I believe that in a child over a year old +the risk is almost negligible. + +Fortunately in all save the rarest possible instances the apnoea +yields and a deep inspiratory movement follows. As the air rushes past +the glottis, which is still partially closed, a sound recalling the +whoop of pertussis is heard. Often this recurs throughout all the +burst of crying which follows, and each inspiration is accompanied by +a shrill stridulous sound. With the re-establishment of respiration +the cyanosis rapidly fades, to be succeeded in some cases by pallor +and perspiration. + +It need hardly be said that we should do all in our power to prevent +these alarming and distressing attacks. Each seizure predisposes to a +repetition. In some children we notice that months and even years +after an attack of whooping-cough, a slight bronchial catarrh may be +sufficient to bring back the characteristic cough. In laryngismus in +the same way we may suppose that the reflex path is made easy and the +resistance lowered by constant use. Fortunately the spasms are not +usually difficult to control. Calcium bromide, in doses of from two to +four grains, according to age, three times daily, is generally +successful with or without the addition of chloral hydrate in small +doses. At the same time we must endeavour in every way possible to +keep the child calm, by paying close attention to nursery management. +The child with spasmophilia is as a rule excitable and easily upset, +and although calcium bromide is a drug which offers powerful aid it is +not able to achieve its effect unless we are able at the same time to +guarantee a reasonable immunity from emotional upsets. It is for this +reason that I have included some description of laryngismus, although +its origin is undoubtedly very different from that of the other +disorders of conduct which we have examined. + + +MIGRAINE AND CYCLIC VOMITING + +The ætiology of cyclic or periodic vomiting in childhood is not yet +completely understood. We do not know how far it is dependent upon +disturbance of the liver, and it is still disputed whether the +acidosis which accompanies it is the cause or the result of the +profuse vomiting. Into these difficult questions we need not at the +moment enter. It is enough in the present connection to recognise that +the great majority of children who suffer from cyclic vomiting are +sensitive, excitable, and nervous, and that every one is agreed that +the nervous system is intimately concerned in its causation. + +A close association between cyclic vomiting in children and that form +of periodic headache known as migraine has often been observed. It is +sometimes found that one or both parents of a child with cyclic +vomiting suffer habitually from migraine. In a few instances the one +condition has been observed to be gradually replaced by the other, the +child with cyclic vomiting becoming in adult life a sufferer from +migraine. There is indeed much which is common to the two conditions. +The periodic nature of the seizure, often following a time when the +general health and vigour appear to have been at their optimum, the +extreme prostration, and the comparatively sudden recovery are found +in both. In the cyclic vomiting of children, it is true, little +complaint is made of headache, the visual aura is absent, and the +vomiting is invariably the most prominent symptom. + +Cyclic vomiting seldom occurs before the fourth year. It is +characterised by sudden profuse and persistent vomiting and by very +great prostration. All food, it may be even water, is promptly +rejected. The vomited matter is generally stained with bile; +occasionally the violence of the vomiting causes hæmatemesis. In many +cases the temperature is raised; sometimes it may be as high as 103° +F. The duration of an attack varies. In most cases it does not last +longer than forty-eight hours. On the other hand, attacks lasting as +long as a week are by no means unknown. Within a short time of the +onset the urine may be found to contain acetone bodies, the breath may +smell distinctly of acetone, and the child may become torpid and +drowsy or agitated and restless. At times there may be exaggerated and +deepened respiratory movements--the so-called air hunger. In many +cases, however, otherwise characteristic, these more severe +manifestations are absent or but little apparent. Recovery is usually +rapid and complete. The child asks for food, which is retained. A +fatal ending is very rare, though not unknown. The frequency of +attacks is very various. Sometimes months or even years may elapse +between successive seizures; in other cases a fortnightly or monthly +rhythm establishes itself. + +It is clear that both the frequency and the severity of the attacks +are much influenced by the general state of the child's health. Like +migraine, cyclic vomiting appears to be a symptom of nervous +exhaustion. It affects, for the most part, children who are +intellectually alert, impressionable, and forward for their age, and +who, when well, throw themselves into work or play with a great +expenditure of nervous energy. Often their physical development is +unsatisfactory, and we must set ourselves to correct this as the first +step in prevention. It is highly important that children suffering in +this way should have free opportunities for exercise in the open +country, and that all the excretory organs--the skin, kidneys, and +bowels--should be acting freely and efficiently. The child should live +a life of ordered routine. Sleep should be sound and sufficient in +amount. The diet must not exceed the strict physiological needs. Many +of these children appear to have a lowered tolerance for fats of all +sorts, and it may be necessary to limit strictly the consumption of +milk, cream, butter, and so forth. A daily administration of a small +dose of alkali by the mouth is credited with preventing attacks. In +the present connection, however, we shall not do wrong to emphasise +the part played by the nervous system in the production of the +attacks. In all cases of cyclic vomiting it should be our endeavour to +recognise and remove the elements in the daily life of the child which +are proving too exhausting. + +UNEXPLAINED PYREXIA + +In nervous children we sometimes meet with inexplicable rises of +temperature. The pyrexia may have the same periodic character as that +just noted in cases of cyclic vomiting. At intervals of three, four, +or five weeks there may be a rise of temperature to 103° F., or even +higher, which may last for two or three days before subsiding. In +other cases the chart shows a slight persistent rise over many weeks +or months. That in nervous children the temperature may be very +considerably elevated without our being able to detect much that is +amiss does not of course make it any the less necessary to be careful +to exclude organic disease. Pyelitis, tuberculosis, and latent otitis +media occur with nervous children as with others and must not be +overlooked. If, however, organic disease can be excluded, and if the +pyrexia is the only circumstance which prevents the decision that the +child is well and should be treated as well, then the thermometer may +be overruled and the pyrexia neglected. + + + + +CHAPTER VI + +ENURESIS + + +I have dealt in previous chapters with certain common disorders of +conduct in childhood, which show clearly their origin in the +apprehensions of the grown-up people who have charge of the children, +and in the unwise suggestions which they convey to them. The same +forces are at work in the production of enuresis, or bed wetting, +although the matter is here often complicated by the development later +on of a sense of shame and unhappiness in the child. There comes a +time when the child passionately desires to regain control and is +miserable about her failure, until the concentration of her thoughts +on the subject becomes a veritable obsession. Every night she goes to +bed with this only in her mind. Every night she falls asleep, +miserably aware that she will wake to find the bed wetted. The +suggestion impressed in the first place on the mind of the tiny child +by injudicious management has become fixed by the growing sense of +shame and the complete loss of self-confidence. + +It is usually taught that a great variety of causes is concerned in +producing enuresis. It is said to be due to a partial asphyxia during +sleep from adenoid vegetation. It is said to be caused by phimosis, +and to be cured by circumcision. It is said that the urine is often +too acid and so irritating that the bladder refuses to retain it for +the usual length of time. It is said that enuresis may be due to a +deficiency of the thyroid secretion, and that it can be cured by +thyroid extract. Such a number of rival causes may make us hesitate to +accept the claims of any one of them. Certainly I have not been able +to satisfy myself that any one of these conditions exercises any +influence at all or is commonly present in cases of enuresis. I think +that if we examine a large number of cases of bed wetting in children +we can come to no other conclusion than that the cause of the trouble +is due to just such a pervasion of suggestion as we have been +considering above. + +There are certain points in the behaviour of a child with enuresis +which seem to point to this conclusion. + +_(a)_ In the first place, the trouble is seldom serious or very well +developed in early childhood, and the reason for this, I take it, is +that an occasional lapse in a child of perhaps two or three years of +age is usually treated lightly and in the proper spirit of tolerance. +It is only with children a little older that nurses and parents become +distressed and begin unwittingly by urging the child to present the +suggestion to her mind, that the bed may or will be wetted. Hence the +usual history is that control was partially acquired in the second +year, but that, instead of later becoming complete, relapses began to +be more frequent, and that since that time all that can be done seems +only to make matters worse. + +_(b)_ In the second place, the influence of suggestion is shown by the +behaviour of the child when removed to a hospital for observation. It +is the invariable experience that the enuresis then promptly stops. In +hospital the attitude of those around the child is entirely different. +She has the comfortable and consoling feeling that in wetting the bed +she is doing exactly what is expected of her. There is even a feeling +that otherwise she is showing herself to be something of a fraud, and +that she has then been admitted to the hospital on false pretences. +Hence, perhaps for the first time in many years, the child is free +from the obsession, and the bed is not wetted. + +_(c)_ In the third place, it is easy to recognise in the history of +many of the cases, the ill-effects of circumstances which add new +force to the fear of failure or shake the confidence in the control +which had been regained. Thus a boy, an only child, who had suffered +from enuresis till his seventh year, had regained complete control +till his eleventh year, when he went to school. In his dormitory at +school was a boy who had enuresis, and who was being fined and +punished by the schoolmaster. The enuresis at once reappeared and +continued unchecked so long as he was at school. As might be expected, +school life is very inimical to cure, unless the trouble can be kept +from the knowledge of the other boys. Anything which directly +increases the nervousness of the child--an illness, for example, with +loss of weight and failure of nutrition, or some mental stress, such +as the approach of an examination--is apt to accentuate the enuresis. + +_(d)_ In the fourth place, the incontinence sometimes spreads to the +daytime, and the child is wet both by day and night. Further, in bad +cases it is not uncommon to find incontinence of fæces making its +appearance also. These extensions of the fault only take place when +the management continues to be very faulty, when the grown-up people +around them are more than usually distressed and pessimistic, and have +redoubled their expostulations and appeals. + +Now these peculiarities of enuresis seem to me only explicable if we +assume that the want of control is due to auto-suggestion, dependent +at the beginning on the unwise attitude adopted towards the fault by +the nurses and parents, and later kept up by the sense of shame and +the mental distress involved. + +The forms of treatment which have been recommended from time to time +are, as might be expected, very numerous. + +_(a) Operative._--(i) Removal of tonsils and adenoids, (ii) +Circumcision. + +_(b) Manipulative._--(i) Injection of saline solution under the skin +in the perineal and pubic regions, with object of lowering the +excitability of the bladder by counter-irritation. (ii) Gradual +distension of the bladder by hydrostatic pressure, (iii) Tilting the +foot of the bed so as to throw the urine to the fundus of the +bladder, in order to protect the sensitive trigone from irritation. + +_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the +child at intervals during the night by an alarm clock or otherwise. +(iii) Rewards and punishments. + +_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract. + +_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic +suggestion. + +I do not think that any single one of these various forms of treatment +outlined under the first four heads has any effect other than to aid +the suggestion of cure which we proffer in adopting it. Removal of +tonsils and adenoid vegetations might conceivably cure an enuresis +which is nocturnal, it cannot account for an incontinence which +spreads to the day. We might believe that to distend the bladder by +hydrostatic pressure was a cure for incontinence of urine, and that it +acted by removing the local cause,--the smallness and contraction of +the bladder,--were it not that the loss of control is so apt to spread +to the rectum as well. There is no evidence that the urine is +peculiarly irritating. Indeed, such evidence as we have goes to show +that, as in some other neuroses, the urine in enuresis is unduly +copious, and of very low specific gravity. Incidentally, we have in +this polyuria a further argument against the view recently advanced +that a small and contracted irritable bladder is the cause of +enuresis. We do, of course, meet with cases of irritable bladder often +enough, but the complaint is then not of incontinence, but always of +the discomfort of having to rise so frequently for micturition. + +To deprive the child of fluid, to wake her many times at night, to +tilt the foot of the bed, are devices which may help in the hands of +some one who is confident of his ability to cure the condition and can +communicate the confidence to the child. Carried out hopelessly and +pessimistically by a tired and exasperated mother, they are well +calculated to strengthen the hold which the obsession has on the +child, so that often we meet with a mother who rightly enough +maintains that the more she wakes the child, the oftener the bed is +wet, till she wonders where it all comes from. + +The treatment of enuresis to be successful must be conducted through +and by means of the grown-up persons who have the control of the +children. To stop the development of enuresis in early infancy we must +intervene to prevent the concentration of the child's mind on the +difficulty. During the time when control is ordinarily developed, in +the second and third year, judicious management of the child is +essential. The emphasis should be laid upon successes, not upon +failures. For every child his reputation will sway in the balance for +a time. He must be helped and encouraged to self-confidence, not +rendered diffident or self-conscious. + +If the case is well established before it comes under our notice, the +mother, the nurse, the schoolmaster, or whoever is responsible for the +child's management, must understand clearly the nature of the trouble. +The suggestion acting on the child's mind must be altered, and +self-confidence restored. The child must learn to see that the thing +is not so desperately tragic. He should be told that the trouble +always gets well, and that it only goes on now because he is worried +about it and keeps thinking of it. If the whole environment of the +child is bad, so that such a change of suggestion is not possible, and +if enuresis is but one of many symptoms of mental or moral +instability, it may be necessary to remove the child and place him +under the influence of some one else. Sometimes the prescription of a +rubber urinal, which the child can slip on at night, is directly +curative. A public school boy, who was about to be sent away from +school for this failing, fortified by the possession of this +apparatus, wrote six months later to say that he knew now that it must +be all worry that caused the trouble, because with the urinal in +position he had not once had the incontinence. + +In inveterate cases hypnotic suggestion is always, I think, +successful. It is obvious, however, that in many cases there are +objections to its use. Often enuresis is evidence that the child's +home environment has been at fault, and that his mental and moral +development has been retarded. It is the management which must be +modified or the home, if necessary, changed. Hypnotic suggestion will +make this one symptom disappear promptly enough, but it will rather +perpetuate than combat the cause--that undue susceptibility to +suggestion, which is characteristic alike of the little child and of +many older neuropathic persons. + + + + +CHAPTER VII + +TOYS, BOOKS, AND AMUSEMENTS + + +Any one who has an opportunity of watching little children must have +observed that they are happiest and most contented when playing alone. +The education of the little child is carried on by means of games and +toys. Handling the various objects which we give him, imparting +movement to them, transferring them from hand to hand and from one +situation to another, he learns dexterity and precision of movement, +and in the process hand and brain grow in power. When at play, his +whole energies should be absorbed to the exclusion of everything else. +He will often be oblivious to everything that is going on around him, +intent only on the purpose of the moment. In order to permit this +fervour of self-education it is necessary that the child should be +accustomed to playing alone, and it is well, if only for convenience' +sake, that he should be accustomed to playing in a room by himself. +Something is wrong if the child cannot be left for a few moments +without breaking into tears or displaying bad temper. Engrossed in his +own tasks, he should be content to leave his nurse to move in and out +of the room without protest. If this fault has appeared and the child +cannot be left alone, our whole educational system is undermined, and +play will be profitless and over-exciting, because it demands the +constant participation of grown-up people. As a preliminary to all +improvement in the management of a nervous child, we must see to it +that he becomes accustomed to being alone. We must so arrange his +nursery that he can do no damage to himself. Scissors and matches must +not be left lying about, and a fireguard must be fixed in position so +that it cannot be disturbed. Then, disregarding his protests, the +nurse must leave him to himself, at first only for a moment or two, +re-entering the room in a matter-of-fact way without speaking to him, +and again leaving it. Soon he will learn that a temporary separation +does not mean that we have abandoned him for all time. Then the period +of absence can be gradually lengthened till all difficulty disappears. +Once his attention is removed from the grown-up people who mean so +much to him, his natural impulse to explore and experiment with his +playthings will show itself. Those toys are best which are neither +elaborate nor expensive. For a little child a small box containing a +miscellaneous collection of wooden or metal objects, none of them +small enough to be in danger of being swallowed, forms the material +for which his soul craves. Everything else in the room may be out of +his reach. A dozen times he will empty the box and then replace each +object in turn. He will arrange them in every possible combination, +and then sweep the whole away to start afresh. + +At eighteen months of age observation and imitative capacity will +have made more complex pursuits possible. As a rule the objects which +are most prized and which have most educative value are those which +lend themselves best to the actions with which alone the child is +familiar. Hence the supreme importance of the doll and the doll's +perambulator. The doll will be treated exactly as the child is treated +by the nurse. It will be washed, and dressed, and weighed, and put to +bed in faithful reproduction of what the child has daily experienced. +Dusting, and sweeping, and laying the table will be exactly copied. If +a child has no opportunity of being familiar with horses, if he has +not seen them fed, and watered, and groomed, and harnessed, he may not +find any great satisfaction in a toy horse, or pay much attention to +it, no matter how costly or realistic it may be. + +In the third year more precise tasks, such as stringing beads, +drawing, and painting, will play their part, while at the same time +the increased imaginative powers will give attraction to toy soldiers +or a toy tea-service. Playing at shop, robbers, and rafts are +developments of still later growth. In the child's games we recognise +the instinct of imitation--playing with dolls, sweeping and dusting, +playing at shop or visitors; the instinct of constructiveness--making +mud pies and sand castles, drawing or whittling a stick; and the +instinct of experiment--letting objects fall, rattling, hammering, +taking to pieces. All this activity must be encouraged, never unduly +repressed or destroyed. But whatever form it takes, the bulk of the +play must be carried on without the intervention of grown-up persons, +or it will lose its educative value and prove too exacting. If +grown-up people attempt to take part, the child will lose interest in +the play and turn his attention to them. + +Children differ very much in their attitude towards books. One child +quite early in the second year will be happy poring over picture +books, while another will seldom glance at the contents and finds +pleasure only in turning over the pages, opening and shutting them, +and carrying them from place to place. Such differences are natural +enough and foreshadow perhaps the permanent characteristics that +divide men and women, and produce in later life men of thought and men +of action, women who are Marthas and women who are Marys. +Nevertheless, we should bear in mind that there is danger in a +training that is too one sided, and that books and toys have both +their part to play in developing the powers of the child. All the +activities of the child should be used in as varied a way as possible. +The eye is but one doorway to knowledge and understanding, the ear is +another, the hand a third. + +From pictures an imaginative child will derive very strong +impressions, and mothers should be careful in their choice. It is +foolish to confuse the growth of æsthetic perceptions by presenting +children with books which depict children as grotesquely ugly beings +with goggle eyes and heads like rubber balls. Children love animals +and endow them with all their own reasoning attributes, and in +stories of the home life of rabbits, and bears, and squirrels they +take a pure delight. Books of the "Struwwelpeter" type are less to be +recommended. The faults which they are intended to eradicate become +peculiarly attractive from much familiarity. A little boy of two and a +half who resolutely refused all food for some days was in the end +detected to be playing the part of that Augustus, once so chubby and +fat, who reduced himself to a skeleton, saying, "Take the nasty soup +away; I don't want any soup to-day." Tales of naughty children who +meet with a distressing fate may either frighten the child unduly, or +else produce in a child of inquiring mind the desire to brave his fate +and put the matter to the test. Pictures should not be terrifying or +horrible. Ogres devouring children are out of place as subjects for +pictures and may cause night-terrors. + +Children should be taught to be careful of books and toys. The +indestructible book, generally falsely so called, is often responsible +for the immediate dissolution of all others less protected which come +to hand. The sympathy which little children have with the sufferings +of all inanimate objects and their habit of endowing them with their +own sensations may be made of use in teaching them care and +gentleness. They are naturally prone to sympathise with the doll that +has been crushed or the book that has been torn. They will learn very +easily to be kind to a pet animal and to be solicitous for its +feelings, and the lesson so learnt will be applied to inanimate +objects as well. + +There is, however, another side to the question. It is true that if +the child is not to be over-stimulated upon the psychical side, we +must see to it that his play, for the most part, is not dependent upon +the participation of grown-up persons. In practice this excessive +stimulation is the common fault with which we meet. There are few +children in well-to-do homes, with loving mothers and devoted nurses, +who suffer from too little mothering and nursing. Too many show signs +of too much. To observe the opposite fault we must seek the infants +and children who for a long time are inmates of institutions, +orphanages, infirmaries, hospitals, and so forth. In such surroundings +the mental life of the child may languish. His physical wants are +cared for, but there the matter ends. In a rigid routine he is washed +and fed, but he may not be talked to or played with or stimulated in +any way. His day is spent passively lying in his cot, unnoticed and +unnoticing. I have seen a poor child of three years just released from +such a life, and after eighteen months returned to his mother, unable +to talk and almost unable to walk, crying pitifully at the novelty and +strangeness of the noisy life to which he had returned, worried by +contact with the other children, and without any desire or power to +occupy himself in the home. For an hour in the day mothers may devote +themselves wholeheartedly to the children, and if they set them +romping till they are tired out, so much the better. In the garden or +in an airy room with the windows open, a game with a ball or a toy +balloon, or a game of hide-and-seek, will be all to the good, and the +children may climb and be rolled over and swung about to their heart's +content. With an only child, especially with a child whose home is in +town, and whose outings are limited to a sedate airing in the park, +such free play is especially necessary. It may help more than anything +else to quiet restless minds and tempers that are on edge all day long +from excessive repression. + +On the other hand, those forms of entertainment which are known as +"children's parties" are generally fruitful of ill results, at any +rate with nervous and highly-strung children. Sometimes they entail a +postponement of the usual bedtime, and nearly always they involve +over-heated and crowded rooms. Perverse custom has decreed that these +gatherings shall take place most commonly in the winter, when dark and +cold add nothing to the pleasure and a great deal to the risk of +infection which must always attend the crowding of susceptible +children together in a confined space with faulty ventilation. There +is clearly on the score of health much less objection to summer garden +parties for children, but these for some reason are less the vogue. As +a rule parties are not enjoyed by nervous children. There is intense +excitement in anticipation, and when at length the moment arrives, +there is apt to be disillusion. Either the excitement of the child may +pass all bounds and end in tears and so-called naughtiness, or the +unfamiliar surroundings may leave him distrait with a strange sense of +unreality and unhappiness. It is not always fair to blame the want of +wisdom in his hostess's choice of eatables, if the excited and +overstimulated child fails in the work of digestion and returns to the +nursery to suffer the reaction, with pains and much sickness. + +The same arguments may be urged against taking little children to the +theatre. The nerve strain is apt to be out of proportion to the +enjoyment gained. If children must go to theatres and parties, the +treat should be kept secret from them until the moment of its +realisation, in order that the period of mental excitement should be +contracted as much as possible, and grown-up people should be advised +to treat the whole expedition in a matter-of-fact sort of way that +does nothing to add to the excitement or increase the risk of +subsequent disillusion. + + + + +CHAPTER VIII + +NERVOUSNESS IN EARLY INFANCY + + +We may now pass back to consider the nervous system of the child in +infancy. There, too, from the moment of birth there are clearly-marked +differences between individuals. The newborn baby has a personality of +his own, and mothers will note with astonishment and delight how +strongly marked variations in conduct and behaviour may be from the +first. One baby is pleased and contented, another is fidgety, +restless, and enterprising. At birth the baby wakes from his long +sleep to find his environment completely changed. Within the uterus he +lies in unconsciousness because no ordinary stimulus from the outer +world can reach him to exert its effect. He lies immersed in fluid, +which, obeying the laws of physics, exercises a pressure which is +uniformly distributed over all points of his body. No sound reaches +him, and no light. After birth all this is suddenly changed. The sense +of new points of pressure breaks in upon his consciousness. Cold air +strikes upon his skin. Loud sounds and bright lights evoke a +characteristic response. A placid child who inherits a relatively +obtuse nervous organisation will be but little upset by this sudden +and radical change in the nature of his environment. His brain is +readily but healthily tired by the new sensations which stream in from +all sides, and he falls straight away into a sleep from which he +rouses himself at intervals only under the impulse of the new +sensation of hunger. + +Babies of nervous inheritance, on the other hand, will show clearly by +the violence of the response provoked that their nervous system is +easily stimulated and exhausted. They will wriggle and squirm for +hours together, emitting the same constant reflex cry. The whole body +will start convulsively at a sudden touch or a loud sound which would +evoke no response from a more stolid infant. The sleeplessness and +crying exhaust the baby, rendering the nervous system more and more +irritable, while the sensation of hunger which is delayed in other +children by twelve hours or more of deep sleep appears early and is of +extreme intensity. We must see to it that sense stimuli are reduced to +the lowest possible level. True, we cannot again restore the child to +a bath of warm fluid, of the same temperature as his body, where he +can be free from irksome pressure and from all sensations of sound and +light, but we can so arrange matters that he is not disturbed by loud +sounds and bright lights, and that he is not moved more than is +necessary. Sudden unexpected movements are especially harmful. Jogging +him up and down, patting him on the back, expostulation, and +entreaties are all out of place and do all the harm in the world. The +first bath should be as expeditious as possible, and above all the +baby must not be chilled by tedious exposure. Cold irritates his +nervous system more than anything else, unless it be excessive warmth. +In preserving the proper temperature so that we do not render the +child restless by excess of heat or by excess of cold, we +too-civilised people have made our own difficulties. We have +exaggerated the completeness of the sudden separation of mother and +child which nature decrees. It is the function of all mother animals +to approximate the unstable temperature of the newly born to their own +by the close contact of their bodies, which provide just the proper +heat. Labour is nowadays so complicated and exhausting a process for +mothers that, all things considered, we are wise in completing the +separation of mother and child and in removing the baby to his own +cot. But the difficulty remains, and we must arrange that any +artificial heating needed is constant and of proper degree. + +If the baby is very restless and irritable, too wide awake and too +conscious of his surroundings, the all-important task of getting him +to the breast and getting him to draw the milk into the breast is apt +to be difficult. His sucking is a purely reflex and involuntary act. +It can be produced by anything which gently presses down the tongue, +and a finger placed in the proper position will provoke the movement +without the child's consciousness being aroused. The placid child +whose mind is at rest will suck well and strongly. If, on the other +hand, the brain is too much stimulated and the child is restless and +irritable, the reflex act of suction is inhibited, and it is a +difficult matter to get the child to the breast. He is too eager, +mouthing, and gulping, and spluttering. Or sometimes his mental +sufferings seem too much for his appetite, and though wide awake and +crying loudly, he refuses to grasp the nipple, turning his head away +and wriggling blindly hither and thither. This effect of mental unrest +on the newborn infant is often disastrous, because it is one of the +common causes of the failure of women to nurse their children. This is +not the place to sketch in detail a scheme for the proper technique of +breast nursing, a matter which is much misunderstood at the present +day. It will be enough shortly to say that an efficient supply of milk +depends upon the complete and regular emptying of the breast. The +breasts of all mothers will secrete milk if strong and vigorous +suction is applied to the nipple by the child. If anything interferes +with suction, the milk does not appear or, if it has appeared, it +rapidly declines in amount. The mother's part is to a great extent a +passive one, provided that she can supply one essential--a nipple that +is large enough for the child to grasp properly. Within wide limits +what the mother eats or drinks, whether she be robust or whether she +has always been something of an invalid, matters not at all. A frail +woman may naturally not be able to stand the strain of nursing for +many months, but that is not here the point in question. We are +dealing only with the establishment of lactation and with the milk +supply of the early days and weeks which is of such vital importance +for the child. If the mother is ill, if, for example, she has +consumption, we may separate her from the child in the interests of +both; but if this is not done, she will continue to secrete milk for a +time as readily as if she were in perfect health, and the breasts of +many a dying woman are to be seen full of milk. Mothers are too apt to +attribute the disappointment of a complete failure to nurse to some +weakness or want of robustness in their own health. This is never the +reason of the failure, and the fault, if the mother has a well-formed +nipple, is generally to be found in some disturbance in the child. +Prematurity, with extreme somnolence, breathlessness from respiratory +disease, nasal catarrh, which hinders breathing through the nose, +infections of all sorts, are common causes of this failure to suck +effectively. But perhaps the most common cause of all is the +inhibition from nervous unrest of that reflex act of sucking which +works so well in the placid and quiet child. It is a point to which +too little attention is paid, and mothers and the books which mothers +read commonly neglect the nervous system of the child and devote +themselves to such considerations as the relative merits of two-hourly +and four-hourly feedings--important points in their way, but less +important than this. + +The matter is complicated in two other ways. In the first place, the +nervous baby, just because he is so active and wakeful and restless, +is apt rapidly to lose weight and to have an increased need for food. +The restlessness is generally attributed to hunger, and this is true, +because hunger is soon added to the other sensations from which he +suffers, and like them is unduly acute. It is difficult not to give +way and to provide artificial food from the bottle. Yet if we do so we +must face the fact that these restless little mortals are quicker to +form habits than most, and once they have tasted a bottle that flows +easily without hard suction, they will often obstinately refuse the +ungrateful task of sucking at a breast which has not yet begun to +secrete readily. The suction that is devoted to the bottle is removed +from the breast, and the natural delay in the coming in of the milk is +increased indefinitely. At the worst, the supply of milk fails almost +at its first appearance. We must devote our attention to quieting the +nervous unrest by removing all unnecessary sensory stimulation from +the baby. He must be in a warm cot, in a warm, well-aired, darkened, +and silent room, and the necessary handling must be reduced to a +minimum. Sometimes sound sleep will come for the first time if he is +placed gently in his mother's bed, close to her warm body. If he is +apt to bungle at the breast from eagerness and restlessness, it is not +wise always to choose the moment when he has roused himself into a +passion of crying to attempt the difficult task. So far as is possible +he should be carried to the breast when he is drowsy and sleepy, not +when he is crying furiously, and then the reflex sucking act may +proceed undisturbed. + +In the second place, we must guard against the ill effect which the +ceaseless crying of these nervous babies has upon the mother. She may +be so exhausted by the labour that her nerves are all on edge, and she +grows apprehensive and frightened over all manner of little things. +The tired mother is apt to fear that she will have no milk, and her +agitation grows with each failure on the part of the child. Now the +first secretion of milk is very closely dependent upon the nervous +system of the mother. We have said that within wide limits her +physical condition is of less importance, but her peace of mind is +essential. And so it is wise for some part of the day to keep the +nervous baby out of hearing of the mother, and so far as possible to +choose moments when the child is quiet to put him to the breast. A +nurse with a confident, hopeful manner will effect most; a fussy, +over-anxious, or despondent attitude will do untold harm. We shall +sometimes fail if the nervous unrest is very obstinate either in +mother or in child, but we shall fail less often if we diagnose the +cause correctly in the cases we are considering. Lastly, it is +possible to control the condition in both mother and child by the +careful use of bromide or chloral. + +It is not, of course, suggested that these drugs should be given +freely or as a routine to every hungry baby wailing for the breast, or +that we can hope to combat or ward off an inherited neuropathy by a +few doses of a sedative. There are, however, not a few babies in whom +there develops soon after birth a sort of vicious circle. They can +suck efficiently and digest without pain only when they sleep soundly. +If they are put to the breast after much crying and restlessness, +each meal is followed by flatulence, colic, and renewed crying. The +only effective treatment is to secure sleep and to carry a slumbering +or drowsy infant to the breast. Then the sucking reflex comes to its +own again, the breast is drained steadily and well, and digestion +proceeds thereafter without disturbance and during a further spell of +sleep. Two or three times in the day we may be forced, as meal-time +approaches, to cut short the restlessness of the child by giving a +teaspoonful of the following mixture: + +Pot. brom., grs. ii. [2 grains] + +Chloral hydrate, gr. i. [1 grain] + +Syrup, M x. [10 minims] + +Aq. menth. pip., ad 3 i. [1 dram] + +After this has been taken the child should be laid down for a quarter +of an hour until soundly asleep. Then very gently he can be carried to +his mother and the nipple inserted. If in this way a few days of sound +sleep and less disturbed digestion can be secured, the difficulty will +in most cases permanently be overcome. The steadier suction and more +efficient emptying of the breast will promote a freer flow of milk, +and the deeper and more prolonged sleep will lower greatly the needs +of the child for food. Most of the babies who show this fault are +thin, meagre, and fidgety, and with some increase of muscular tone. +The head is held up well, the limbs are stiff, the hands clenched, the +abdomen retracted, with the outline of the recti muscles unusually +prominent. If we can relax this exaggerated state of nervous tension, +if we can help them to become fatter and to put on weight, the +dyspepsia will disappear with the other symptoms. + +It is a question still to be answered whether the rare conditions of +pyloric spasm and pyloric hypertrophic stenosis are not further +developments of the same disturbance. Certainly these grave +complications appear most commonly in infants with a pronounced +nervous inheritance, and, as might be expected, they are more commonly +found in private practice than among the hospital classes. + +In passing, we may note that there are babies who exhibit the opposite +fault, and in whom the contrary regimen must be instituted. Premature +children, children born in a very poor state of nutrition, and +children born with great difficulty, so that they are exhausted by the +violence of their passage into the world, are apt to show the opposite +fault of extreme somnolence. They are so little stimulated by their +surroundings, and they sleep so profoundly, that the sucking reflex is +not aroused. Put to the breast they continue to slumber, or after a +few half-hearted sucking movements relapse into sleep. We must rouse +such children by moving them about and stirring them to wakefulness +before we put them to the breast. + +Once the child has been got to the breast, once the milk has become +firmly established, we have overcome the first great difficulty which +besets us in the management of nervous little babies, but it is by no +means the last. Restlessness and continual crying must be combated or +digestion suffers, and may show itself in a peculiar form of explosive +vomiting, which betokens the reflex excitability and unrest of the +stomach. + +The sense of taste is as acute as all other sensations. If the child +is bottle-fed, the slightest change in diet is resented because of the +unfamiliar taste, and the whole may promptly be rejected. The tendency +to dyspeptic symptoms is apt to lead to much unwise changing of the +diet, and everything tried falls in turn into disrepute, until perhaps +all rational diets are abandoned, and some mixture of very faulty +construction, because of its temporary or accidental success, becomes +permanently adopted--a mixture perhaps so deficient in some necessary +constituent that, if it is persisted with, permanent damage to the +growth of the child results. We must pay less attention to changes of +diet and explore our management of the child to try and find how we +can make his environment more restful. + +It is wise to accustom a nervous child from a very early age to take a +little water or fruit juice from a spoon every day. Otherwise when +breast-feeding or bottle-feeding is abandoned one may meet with the +most formidable resistance. Infants of a few months can be easily +taught; the resistance of a child of nine months or a year may be +difficult to overcome. The difficulty of weaning from the breast +recurs with great constancy in nervous children. By this time the +influence of environment has become clearly apparent. The child is +often enough already master of the situation, and is conscious of his +power. Such children will sometimes prefer to starve for days +together, obstinately opposing all attempts to get them to drink from +a spoon, a cup, or even a bottle. When this happens, sometimes the +only effective way is to change the environment and to send the baby +to a grandmother or an aunt, where in new surroundings and with new +attendants the resistance which was so strong at home may completely +disappear. When weaning is resented, and difficulties of this sort +arise, it is clear that the mother, whose breast is close at hand, is +at a great disadvantage in combating the child's opposition. + +For nervous infants, alas! broken sleep is the rule. What, then, is to +be done? It is astonishing to me that any one who has studied the +behaviour of only a few of these nervous and restless infants should +uphold the teaching that the crying of the young infant is a bad +habit, and that the mother who is truly wise must neglect the cry and +leave him to learn the uselessness of his appeals. It is true that the +youngest child readily contracts habits good or bad. Either he will +learn the habit of sleep or the habit of crying. Mercifully the +inclination of the majority is towards sleep. But to encourage habits +of restlessness and crying there is no surer way than to follow this +bad advice and to permit the child to cry till he is utterly exhausted +in body and in mind. It is unwise _always_ to rock a baby to sleep; it +is also unwise to allow him to scream himself into a state of +hysteria. A quiet, darkened room, the steady pressure of the mother's +hand in some rhythmical movement, will often quiet an incipient +storm. The longer he cries, the more trouble it is to soothe him. +Sleep provokes sleep, so that often we find restlessness and sound +sleep alternating in a sort of cycle, a good week perhaps following a +bad one. The nurse who is quick to cut short a storm of crying and to +soothe the child again to sleep is helping him to form habits of +sleep. The nurse who leaves him to cry, believing that in time he will +of his own accord recognise the futility of his behaviour, is making +him form habits of crying. A rigid routine in sleep is a good thing, +but the routine belongs to the baby, not to the nurse. The child must +be educated to sleep, not taught to cry. A baby has but little power +of altering his position when it becomes strained or uncomfortable. He +cannot turn over and nestle down into a new posture. If we watch him +wake, the first stirring may be very gradual, and in a moment he may +fall again to sleep. A few minutes later he stirs again more strongly, +and is wider awake and for longer. It may only be after a third +waking, by a summation of stimuli, that he is finally roused and +breaks into loud crying. The nurse who is on the watch, who, sleeping +beside him, wakes at the slightest sound and is quick to turn him over +and settle him into a new position of rest, will probably report in +the morning that the baby has had a good night. The nurse who lets the +child grow wide awake and start crying loudly, will spend perhaps many +hours before quiet is again restored. Of the voluntary, purposive +crying of infants a little older I am not here speaking. Infants in +the second six months are quite capable of establishing a "Tyranny of +Tears" and feeling their power. Fortunately it requires no great +experience to distinguish one from the other, and to adopt for each +the appropriate treatment. + +Again, in elementary teaching upon the management of infants stress is +laid, rightly enough, upon the importance of regularity in the times +of feeding, and on the observance in this respect also of a very +strict routine. But in the case of the very nervous infant a certain +latitude should be allowed to an experienced nurse or mother. We may +wreck everything by a blind adhesion to a too rigid scheme, which may +demand that we leave the child to scream for an hour before his meal, +or that, when at length he has fallen into a sound sleep after hours +of wakefulness, we should proceed to wake him. + +Symptoms of dyspepsia which are due to continued nervous excitement +demand treatment which is very different from that which would be +appropriate to dyspepsia which is due to other causes, such as +overfeeding or unsuitable feeding. The temporary restriction of food, +which is commonly ordered in dyspepsia from these causes, is very +badly supported by the nervous infant. Hunger invariably increases the +unrest, and the unrest increases the dyspepsia. + +The difficulties of managing a nervous infant are very real, and call +for the most exemplary patience on the part of the mother and the +clearest insight into the nature of the disturbance. + + + + +CHAPTER IX + +MANAGEMENT IN LATER CHILDHOOD + + +In the early days in the nursery the actions of the infant, for the +most part, follow passively the traction exercised by nurses and +mothers, sometimes consciously, but more often unconsciously. We have +now to consider a period when the child becomes possessed of a driving +force of his own, and moves in this direction or that of his own +volition. In this new intellectual movement through life he will not +avoid tumbles. He will feel the restraints of his environment pressing +upon him on all sides, and he will often come violently in contact +with rigid rules and conventions to which he must learn to yield. From +time to time we read in the papers of some terrible accident in a +picture-palace, or in a theatre. Although there has been no fire, +there has been a cry of fire, and in the panic which ensues lives are +lost from the crowding and crushing. Yet all the time the doors have +stood wide open, and through them an orderly exit might have been +conducted had reason not given place to unreason. It is the task of +those responsible for the children's education to guide them without +wild struggling along the paths of well-regulated conduct towards the +desired goal, influenced not by the emotions of the moment, but only +by reason and a sense of right; not ignorant of the difficulties to be +met, but practised and equipped to overcome them. + +It is easy thus to state in general terms the objects of education, +and the need for discipline. To apply these principles to the +individual is a task, the immeasurable difficulty of which we are only +beginning to appreciate with the failure of thirty years of compulsory +education before us. A recent writer[2] gives it as his opinion that +the aim of education is to equip a child with ideals, and that this +task should not be difficult, because the lower savages successfully +subject all the members of their tribe to the most ruthless +discipline. Their lives, he says, "are lived in fear, in restraint, in +submission, in suffering, subject to galling, unreasoning, +unnecessary, arbitrary prohibitions and taboos, and to customary +duties equally galling, unreasoning, unnecessary, and arbitrary. They +endure painful mutilations, they submit to painful sacrifices.... How +are these wild, unstable, wayward, impulsive, passionate natures +brought to submit to such a rigorous and cruel discipline? By +education; by the inculcation from infancy of these ideals. In these +ideals they have been brought up, and to them they cling with the +utmost tenacity." One might as well contend that it was easy to teach +all men to live the self-denying life of earnest Christians because +some savage tribe was successful in maintaining among its members a +universal and orthodox worship of idols. The ideals set before the +child are too high and too complex to be inculcated by physical force, +or even by force of public opinion. A rigid discipline, with many +stripes and with terrible threats of a still worse punishment in the +world to come, was the almost invariable lot of children until the +last century was well advanced. Yet has this drastic treatment of +young children fulfilled its purpose? Were the men of fifty years ago +better conducted and more controlled than the men of to-day? In any +one family did a greater proportion turn out well? Is it not true that +at least among the educated classes the relaxation of nursery and +schoolroom discipline which the last fifty years has seen has been +justified by its results? Is it not true that the childhood of our +grandmothers was often lived "in fear, in restraint, in submission, in +suffering subject to galling, unreasoning, unnecessary, arbitrary +prohibitions and taboos, and to customary duties equally galling, +unreasoning, unnecessary, and arbitrary." And though perhaps the +grandmothers of most of us may not have been much the worse for all +this discipline, is it not true that of the little brothers who shared +the nursery with them a surprising number broke straightway into +dissipation when the parental restraints were removed? If we are to +teach a child to be gentle to the weak it is not wise to beat him. The +qualities which we wish him to possess are not more subtle than the +means by which we must aid him to their possession. + +[Footnote 2: _The Principles of Rational Education_, by Dr. C.A. +Mercier.] + +Education comprises physical, mental, and moral training. In earlier +times physical strength and the power to fight well, alone were prized +and were the chief objects to be gained in the education of youth. +Later, under the stress of intellectual competition for success in +life, mental acquirements have come to occupy the first place. We are +only now learning to lay emphasis upon the supreme need for moral +training. Not that it is possible to separate the sum of education +into its constituent parts, and to regard each as distinct from the +others. That many men of great intellectual activity, and many men +pre-eminent for their moral qualities have harboured a great brain or +a noble character in a weakly or deformed body, forms no argument to +disprove the general rule that a healthy, vigorous physique is the +only sure foundation upon which to build a highly developed intellect +and a stable temperament. In childhood the intimate connection between +vigour of mind and vigour of body is almost always clearly shown. A +child with rickets, unable to exercise his body in free play, as a +rule shows a flabbiness of mind in keeping with his useless muscles +and yielding bones. Such children talk late, are infantile in their +habits and ways of thought, and are more emotional and unstable than +healthy children of the same age. The connection between bodily +ailments and instability of nervous control is even more clearly seen +in the frequent combination of rheumatism and chorea. A very high +proportion of older children suffering from the graver neuroses, such +as chorea, syncopal attacks, phobias, tics, and so forth, show +defective physical development. Scoliosis, lordosis, knock-knee, flat +foot, pigeon chest, albuminuria, cold and cyanosed extremities, are +the rule rather than the exception. If the body of the child is +developed to the greatest perfection of which it is capable we shall +not often find a too sensitive nervous system. The boy of fine +physique may have many faults. He may be bad-tempered or untruthful or +selfish, but such faults as he has are as a rule more primitive in +type, more readily traced to their causes, and more easy to eradicate +than the faults which spring from that timidity, instability, and +moral flabbiness which has so often developed in the lax delicate +child reared softly in mind and body. + + +PHYSICAL TRAINING + +Children thrive best in the healthy open-air life of the country, and +if there is any tendency to nervous disturbances the need for this +becomes insistent. Physical training, further, includes the manual +education of the child. The system of child-training advocated by Dr. +Montessori is based upon the cultivation of tactile sensations and the +development of manual dexterity. Exercises such as she has devised +have an immediate effect in calming the nervous system and in changing +the restless or irritable child into a self-restrained and eager +worker. Lord Macaulay, whose phenomenal memory as a child has become +proverbial, was so extraordinarily unhandy that throughout life he had +considerable difficulty in putting on his gloves, while he had such +trouble with shaving that on his return from India there were found in +his luggage some fifty razors, none of which retained any edge, and +nearly as many strops which had been cut to pieces in his irritated +and ineffectual efforts. If we teach a child manual dexterity it is an +advantage to him, because manual dexterity is seldom associated with +restlessness and irritability of mind. To excel in some handicraft not +only bespeaks the possession of self-control, it helps directly to +cultivate it. The teaching of Froebel and Montessori holds good after +nursery days are over. + + +MENTAL TRAINING + +Mental training enables the child to retain facts in his memory, to +obtain information from as many sources as possible, to understand and +piece them together, and finally to reach fresh conclusions from +previously acquired data. So far as is possible the teacher must +satisfy the natural desire to know the reason of things. It must be +his endeavour to prevent the child from accepting any argument which +he has not fully understood, and which, as a result, he is able not to +reconstruct but only to repeat. Mental work which is slovenly and +perfunctory is as harmful to the child's education as mechanical work +which is bungled and ineffective. Taking advantage of his natural +aptitudes, his interest should be developed and extended in every way +possible. Tasks which are accomplished without enthusiasm are labour +expended in vain, because the knowledge so acquired is not +assimilated and adds nothing to the child's mental growth. There +should be no sharp differentiation between work and play. + + +MORAL TRAINING + +Moral training depends upon the force of example rather than of +precept. Parents must be scrupulously just and truthful to the child, +for his quick perception will detect the slightest deceit, and the +evil impression made on his mind may be lasting. They must confidently +expect conduct from him of a high moral standard, and be careful at +this early age to avoid the common fault of giving a dog a bad name. +If it is said on all sides that a child has an uncontrollable temper, +is an inveterate grumbler, is lacking in all power of concentration, +or has a tendency to deceit, it is likely that the child will act up +to his reputation. He comes in time to regard this failing of his as +part of himself just as much as is the colour of his hair or the +length of his legs. It may be said of a schoolboy that he shows no +aptitude for his work. Term by term the same report is brought home +from school, and each serves only to confirm the boy in his belief +that this failing is part of his nature, and that no effort of his own +can correct it. If one subject only has escaped the condemnation of +his master, then it may be to that study alone that he returns with +zest and enjoyment. Spendthrift sons are manufactured by those fathers +who many times a day proclaim that the boy has no notion of the value +of money. + +And so with children! Parents must take it for granted that they will +display all the virtues they desire in them. They must trust to their +honour always to speak the truth, and always to do their best in work +or play whether they are with them or not. Again and again the +children will fail and their patience will be tried to the utmost. +They must explain how serious is the fault, and for the time being +their trust may have to be removed; but with the promise of amendment +it must again be fully restored and the lapse completely forgotten. If +the child feels he is not trusted he ceases to make any effort, and +lapse will succeed lapse with increasing frequency. + +In efforts at moral training there is often too great an emphasis laid +upon negative virtues. It is wrong to do this: to do that is +forbidden. Children cannot progress by merely avoiding faults any more +than a man may claim to be an agreeable companion at table because he +does not eat peas with a knife or drink with his mouth full. There +must be a constant effort to achieve some positive good, to acquire +knowledge, to do service, to take thought for others, to discipline +self, and the parent will get the best result who is comparatively +blind to failure but quick to encourage effort and to appreciate +success. When the child knows well that he is doing wrong, exhortation +and expostulation are usually of little avail if repeated too often, +and serious talks should only take place at long intervals. + +We know how effective the so-called "therapeutic conversation" may be +in helping some overwrought and nervously exhausted man or woman to +regain peace of mind and self-control. After an intimate conversation +with a medical man who knows how to draw from the patient a free +expression of the doubts, anxieties, and fears which are obsessing +him, many a patient feels as though he had awakened in that instant +from a nightmare, and passes from the consulting-room to find his +troubles become of little account. Not a few patients return to be +reassured once more, and derive new strength on each occasion. Yet +visits such as these must be infrequent or they will lose their power. +Now, just as the physician is well aware that his intervention if too +frequently repeated will lose its effect, so the parent must be chary +of too frequent an appeal to the moral sense of the child. At long +intervals opportunity may be taken with all seriousness to set before +the child ideals of conduct, to-speak to him of the meaning of +character and of self-discipline, and of the standards by which we +judge a man or woman to be weak and despicable, or strong and to be +admired. The effect of such an intimate conversation, never repeated, +may persist throughout life. Constantly reiterated appeals, on the +other hand, do more harm than good. To tell a child daily that he is +"breaking mother's heart," or that he is "disappointing his father," +is to debase the moral appeal and deprive it of its strength. + +For everyday use it is best to cultivate a manner which can indicate +to the child that he is for the moment unpopular, but which at the +same time denies to the small sinner the interest of attempting his +own defence. On the other hand, should the child be reasonably in +doubt as to the nature of his offence we must spare no trouble in +explaining it to him. Punishment will be most effective when the child +is convinced that he is rightly convicted. If it is to act as a real +deterrent, he must agree to be punished--a frame of mind which, if it +can be produced, may be welcomed as a sure sign that training is +proceeding along the right lines. + +By physical training, mental training, and moral training the child's +character is formed and self-discipline is developed. With the child +of neuropathic disposition and inheritance matters may not proceed so +smoothly. Reasoning and conduct may be alike faulty, and the nervous +disturbances may even cause detriment to the physical health. Not that +the nervous child requires an environment different from that of the +normal child. The difficulties which the parents will encounter and +the problems which must be solved differ not in kind but in degree. An +error of environment which is without effect in the normal child may +be sufficient to produce disastrous results in the neuropathic. + +It must be granted that there are some unfortunate children in whom +the moral sense remains absent and cannot be developed--children who +steal and lie, who seem destitute of natural affection, or who appear +to delight in acts of cruelty. These moral degenerates need not be +considered here. Serious errors of conduct, however, in children who +are not degenerate or imbecile, frequently arise directly from faults +of management and can be controlled by correcting these faults. +Suppose, for example, that a child is found to have taken money not +his own. The action of the parents faced with this difficulty and +disappointment will determine to a great extent whether the incident +is productive of permanent damage to the child's character. The +peculiar circumstances of each case must be considered. For example, +the parent must bear in mind the relation in which children stand to +all property. The child possesses nothing of his own; everything +belongs in reality to his father and mother, but of all things +necessary for him he has the free and unquestioned use. Unless his +attention has been specially directed to the conception of ownership +and the nature of theft, he may not have reasoned very closely on the +matter at all. Very probably he knows that it is wrong to take what is +not given him, but he does not regard helping himself to some dainty +from a cupboard as more than an act of disobedience to authority. He +may have imbibed no ideas which place the abstraction of money from a +purse belonging to his parents on a different plane, and which have +taught him to regard such an action as especially dishonourable and +criminal. Finally, a child who, undetected, has more than once taken +money belonging to his father and mother, may pass without much +thought to steal from a visitor or a servant. To deal with such a case +effectively, to ensure that it shall never happen again, requires much +insight. If the father, shocked beyond measure to find his son an +incipient criminal, differing in his guilt in no way from boys who are +sent to reformatories as bad characters, convinces the child that +although he did not realise it, he has shown himself unworthy of any +further trust, untold harm will be done. Almost certainly the child +will act in the future according to the suggestions which are thus +implanted in his mind. If the household eyes him askance as a thief, +if confidence is withdrawn from him, he sees himself as others see him +and will react to the suggestions by repeating the offence. The +seriousness of what he has done should be explained to him, and after +due punishment he must be restored completely and ostentatiously to +absolute trust. Only by showing confidence in him can we hope to do +away with the dangers of the whole incident. To inculcate good habits +and encourage good behaviour we must let the child build up his own +reputation for these virtues. It need not make him priggish or +self-satisfied if parents let him understand that they take pride in +seeing him practise and develop the virtue they aim at. For example, +it is desired above all that he should always speak the truth. Then +they must ostentatiously attach to him the reputation of truthfulness +and show their pride in his possessing it. If he falls from grace they +must remember that he is still a child, and that if that reputation is +lightly taken from him and he is accused of a permanent tendency +towards untruthfulness, he is left hopeless and resigned to evil. Let +any mother make the experiment of presenting to her child in this way +a reputation for some particular virtue. For example, if an older +child shows too great a tendency to tease and interfere with the +younger children, let the mother seize the first opportunity which +presents itself to applaud some action in which he has shown +consideration for the others. Let her comment more than once in the +next few days on how careful and gentle the older child is becoming in +his behaviour to the little ones, and in a little the suggestion will +begin to act until the transformation is complete. If, on the other +hand, the mother adopts the opposite course and rebukes the child for +habitual unkindness, she will be apt to find unkindness persisted in. +The criminal records of the nation show too often the truth of the +saying that "Once a thief always a thief." Deprived of his good +repute, man loses his chief protection against evil and his incentive +to good. + +The inability of a child--and especially of a nervous and sensitive +child--to form conceptions of his own individuality except from ideas +derived from the suggestions of others, gives us the key to our +management of him and to our control of his conduct. He has, as a +rule, a marvellously quick perception of our own estimate of him, and +unconsciously is influenced by it in his conception of his own +personality, and in all his actions. Parents must believe in his +inherent virtue in spite of all lapses. If they despair it cannot be +hid from the child. He knows it intuitively and despairs also. It is +then that they call him incorrigible. If it happens that one parent +becomes estranged from the child, despairs of all improvement, and +sees in all his conduct the natural result of an inborn disposition to +evil, while the other parent holds to the opinion that the child's +nature is good, and to the belief that all will come right, then often +enough the child's conduct shows the effect of these opposite +influences. In contact with the first he steadily deteriorates, +affording proof after proof that judgment against him has been rightly +pronounced. In contact with the other, though his character and +conduct are bound to suffer from such an unhappy experience, he yet +shows the best side of his nature and keeps alive the conviction that +he is not all bad. + +The force of suggestion is still powerful to control conduct and +determine character in later childhood. The impetus given by the +parents in this way is only gradually replaced by the driving power of +his own self-respect--a self-respect based upon self-analysis in the +light of the greater experience he has acquired. + + + + +CHAPTER X + +NERVOUSNESS IN OLDER CHILDREN + + +In older children the line which separates naughtiness, fractiousness, +and restlessness from definite neuropathy begins to be more marked. +The nature of the young child, taking its colour from its +surroundings, is sensitive, mobile, and inconstant. With every year +that passes, the normal child loses something of this impressionable +and fluid quality. With increasing experience and with a growing power +to argue from ascertained facts, character becomes formed, and if +tempered by discipline will come to present a more and more unyielding +surface to environment, until finally it becomes set into the +stability of adult age. + +We may perhaps, with some approach to truth, look upon the adult +neurotic as one whose character retains something of the +impressionable quality of childhood throughout life, so that, to the +last, environment influences conduct more than is natural. + +All the emotions of neurotic persons are exaggerated. Disappointments +over trifles cause serious upsets; grief becomes overmastering. +Violent and perhaps ill-conceived affection for individuals is apt to +be followed by bitter dislike and angry quarrelling. On the physical +side, sense perception is abnormally acute, and many sensations which +do not usually rise up into consciousness at all become a source of +almost intolerable suffering. To these most unhappy people summer is +too hot and winter too cold; fresh air is an uncomfortable draught, +while too close an atmosphere produces symptoms of impending +suffocation. + +In some neurotics there is an excessive interest in all the processes +of the life of the body, and when attention is once attracted to that +which usually proceeds unconsciously, symptoms of discomfort are apt +to arise. Thus so simple an act as swallowing may become difficult, or +for the time being impossible. To breathe properly and without a sense +of suffocation may seem to require the sustained attention of the +patient; or again, the voice may be suddenly lost. + +More commonly, perhaps, neuropathy exhibits itself in an undue +tendency to show signs of fatigue upon exertion of any sort, mental or +physical. Sustained interest in any pursuit or task becomes +impossible. Nameless fears and unaccountable sensations of dread +establish themselves suddenly and without warning, and may be +accompanied on the physical side by palpitation, flushing, headache, +or acute digestive disturbances. + +All these manifestations are best controlled by selecting a suitable +environment, and as a rule the character of the environment is +determined by the temperament and disposition of those who live in +close contact with the patient. Like the tiny children with whom we +have dealt so far, the behaviour of neuropathic persons is subject +wholly to the direction of stronger and more dominant natures. With +faulty management at the hands of those around them, no matter how +loving and patient these may be, the conduct of the neurotic tends to +become abnormal. + +In children beyond earliest infancy we recognise a gradual approach to +the conditions of adult life. Fractiousness and naughtiness, +ungovernable fits of temper, inconsolable weeping and inexplicable +fears should disappear with early childhood even if management has not +been perfect. If they persist to older childhood we shall find in an +increasing percentage of cases evidence of definite neuropathic +tendencies which urgently call for investigation and for a precise +appreciation of the nature of the abnormality. It may be that the only +effective treatment is that which we recognise as essential in the +grosser mental disturbances--removal from the surroundings in which +the abnormal conduct has had free play, and separation from the +relatives whose anxiety and alarm cannot be hidden. + +In young nervous children fear is the most prominent psychical +symptom. The children are afraid of everything strange with which they +come in contact. They are afraid of animals, of a strange face, or an +unfamiliar room. Older children usually manage to control themselves, +suppress their tears, and prevent themselves from crying out, but it +is nevertheless easy to detect the struggle. + +Often we find those distressing attacks to which the name +"night-terrors" has been given. The child wakes with a cry,--usually +soon after he has gone to sleep,--sits up in bed and shows signs of +extreme terror, gazing at some object of his dreams with wide-open +startled eyes, begging his nurse or mother to keep off the black dog, +or the man, or whatever the vision may be. Even after the light is +turned up and the child has been comforted, the terror continues, and +half an hour may elapse before he becomes quiet and can be persuaded +to go back to bed. In the morning as a rule he remembers nothing at +all. + +Phobias of all sorts are common in nervous children, and result from a +morbid exaggeration of the instinct for self-preservation. Some cannot +bear to look from a height, others grow confused and frightened in a +crowd; dread of travelling, of being in an enclosed space such as a +church or a schoolroom, or of handling sharp objects may develop into +a constant obsession. I have known a little girl who was seized with +violent fear whenever her father or mother was absent from the house, +and she would stand for hours at the window in an agony of terror lest +some harm should have befallen them. As if with some strange notion of +propitiating the powers of darkness these children will often +constantly perform some action and will refuse to be happy until they +have done so. The same little girl who suffered such torments of +anxiety in her parents' absence would always refuse to go to bed +unless she had stood in turn on all the doormats on the staircase of +her home. Other children feel themselves forced to utter certain words +or to go through certain rhythmical movements. They fully understand +that the fear in their mind is irrational and devoid of foundation, +but they are unable to expel it. Often it is hugged as a jealous +secret, so that the childish suffering is only revealed to others +years afterwards, when adult age has brought freedom from it. We will +do well to try by skilful questioning to gain an insight into the +mental processes of a child when we find him showing an uncontrollable +desire to touch lamp-posts or to stand in certain positions; or when +he develops an excessive fear of getting dirty, or is constantly +washing his hands to purify them from some fancied contamination. + +The treatment of all these symptoms calls for much insight. The +child's confidence must be completely secured, and he must be +encouraged to tell of all his sensations and of the reasons which +prompt his actions. The nervous child has a horror of appearing unlike +other children, and will suffer in silence. If his troubles are +brought into the light of day with kindness and sympathy they will +melt before his eyes. Even night-terrors are, as a rule, determined by +the suppressed fears of his waking hours. If they are provoked by his +experiences at school, by the fear of punishment or by dismay at a +task that has proved beyond his powers, he should be taken away from +school for the time being. Night-terrors are said to be aggravated by +nasal obstruction due to adenoid vegetations. Clothing at night should +be light and porous, and particular attention should be paid to the +need for free ventilation. + +We have spoken in an earlier chapter of the trouble sometimes +experienced in inducing a nervous child to go to sleep. In older +children insomnia is common enough. Even when sleep comes it may be +light and broken, as though the child slept just below the surface of +consciousness and did not descend into the depths of sound and +tranquil slumber. We have often noticed how different is the estimate +of the patient from that of the nurse as to the number of hours of +sleep during the night. The sick man maintains that he has hardly +slept at all, whilst the nurse, drawing us aside, whispers in our ear +that he has slept most of the night. In estimating sleep we have to +consider not only its duration, but also its depth, and the patient +who denies that he has slept at all has lain perhaps half the night +with an active restless brain betwixt sleep and wakefulness. Often +enough when he comes to consider in the morning the problems that +vexed his soul at midnight, he is quite unable to recall their nature, +and recognises them as the airy stuff that dreams are made of. +Although in a sense asleep he may have retained a half-consciousness +of his surroundings and a sense of despair at the continued absence of +a sounder sleep. + +With nervous children we are apt to find sleep which is of little +depth and which constantly shows evidence of a too-active brain. The +body is tossed to and fro, words are muttered, and the respiration is +hurried and with a change in rhythm, because there is no depth of +anæsthesia. The body still responds to the impulses of the too-active +brain. From the nature of his dream--as shown by chance words +overheard--we may sometimes gather hints to help us to find where the +elements of unrest in his daily life lie. Sleep-walking is only a +further stage in this same disorder of sleep, in which the dream has +become so vivid that it is translated into motor action. + +If a child begins to suffer from active sleeplessness we must not make +the mistake of urging him to sleep. He is no more capable than we are +ourselves of achieving sleep by an effort of will power. To urge him +to sleep is likely to cause him to keep awake because we direct his +attention to the difficulty and make him fear that sleep will not +come. If he understands that all that he needs is rest, he will +probably fall asleep without further trouble. + +Day-dreams also may become abnormal, and tell of an unduly nervous +temperament. Any one who watches a little child at play will realise +the strength of his power of imagination. The story of Red Riding Hood +told by the nursery fire excites in the mind of the child an +unquestioning belief which is never granted in later life to the most +elaborate efforts of the theatre. All this imaginative force is +natural for the child. It becomes abnormal only when things seen and +acts performed in imagination are so vivid as to produce the +impression of actual occurrences, and when the child is so under the +sway of his day-dreams that he fails to realise the difference between +pretence and reality. Imagination which keeps in touch with reality by +means of books and dolls and toys is natural enough. Not so +imagination which leads to communion with unseen familiars or to acts +of violence due to the organisation of "conspiracies" or "robber +bands" amongst schoolboys. + +If evidence of abnormal imagination appears, the child must be kept in +close touch with reality. We must give him interesting and rational +occupation, such as drawing, painting, the making of collections of +all sorts, gardening, manual work, and so forth. In older children we +must especially supervise the reading. + +In many nervous children we find a faulty contact with environment, so +that instead of becoming interested in the thousand-and-one happenings +of everyday life and experiences, they become introspective and +self-conscious. As a result, sensations of all sorts, which are +commonly insufficient to arouse the conscious mind, attract attention +and, rising into consciousness, occupy the interest to the exclusion +of everything else. The conscious mind is not capable of being +occupied by more than one thing at a time. If attention is +concentrated upon external matters, bodily sensations, even extreme +pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells +us, hardly feels the scalping-knife as he shouts his death song. The +soldier in the excitement of battle is often bereft of all sense of +pain. On the other hand, the patient who is morbidly self-conscious +becomes oblivious of his surroundings while he suffers intensely from +sensations which are usually not appreciated at all. Self-conscious +children will complain much of breathlessness and a sense of +suffocation, of headache, of palpitation, of intolerable itching, of +the pressure of clothing, or of flushing and a sense of heat. +Excessive introspection influences their conduct in many ways. At +children's parties, for example, they will be found wandering about +unhappy, dazed and unable to feel the reality of the surroundings +which afford such joy to the others; or they may be anxious to join in +play, but finding themselves called upon to take their turn are apt to +stand helplessly inactive, or to burst into tears. At school, though +they may be really quick to learn, they will often be found oblivious +of all that has gone on around them, not from stupidity, but from +inability to dissociate their thoughts from themselves and to +concentrate attention upon the matter in hand. In such a case we must +aim at developing the child's interest to the exclusion of this morbid +introspection. Taking advantage of his individual aptitude, we must +strengthen his hold upon externals in every way possible, and we must +explain to him the nature of his failing and teach him that his +salvation lies in cultivating his capacity for paying attention to +things around him and developing an interest in suitable occupations. + +Fainting fits are not uncommon amongst nervous children from about +the sixth year onwards, and are apt to give rise to an unwarranted +suspicion of epilepsy. In other cases fears have been aroused that the +heart may be diseased. In children who faint habitually the nervous +control of the circulation is deficient. We notice that when they are +tired by play, or when they are suffering from the reaction that +follows excitement of any sort, the face is apt to become pale, and +dark lines may appear under the eyes. Yet there may be no true anæmia +present: it is only that the skin is poorly supplied with blood for +the moment. After a little rest in bed, or under the influence of a +new excitement, the colour returns, and the tired look vanishes. If +children of this type are made to stand motionless for any length of +time, and if at the same time there is nothing to attract their +interest or attention--a combination of circumstances which unhappily +is sometimes to be found during early morning prayers at school--the +want of tone in the blood vessels may leave the brain so anaemic that +fainting follows. The first fainting attack is a considerable +misfortune, because the fear of a recurrence is a potent cause of a +repetition. Standing upright with the body at rest and the mind +vacant, the circulation stagnates, the boy's mind is attracted by the +suggestion, he fears that he will faint as he has done before, and he +faints. Schoolmasters are well aware that if one or two boys faint in +chapel and are carried out, the trouble may grow to the proportion of +a veritable epidemic. It is important that this habit of fainting +should be combated not only by general means to improve the tone of +the body and circulation, but also by taking care that the child +understands the nature of the fainting fit, and the part which +association of ideas plays in producing it. Disease of the heart +seldom gives rise to fainting. + +The same vasomotor instability which shows itself in the tendency to +syncopal attacks is apparent in many other ways. Sudden sensations of +heat and of flushing, equally sudden attacks of pallor, coldness of +the extremities, abundant perspiration,--raising in the mind of the +anxious mother the fear of consumption,--and excessive diuresis are +common accompaniments. A further group of symptoms is provided by the +extreme sensibility of the digestive apparatus. Dyspepsia, +hyperaesthesia of the intestinal tract, viscero-motor atonies and +spasms, and anomalies of the secretions, whether specific like that of +the gastric juice or indifferent like that of the nasal, pharyngeal, +gastric, and intestinal mucus, are all of common occurrence. Whenever +the nervous child is subjected to any exhausting experience, any +excitement, pleasurable or the reverse, or any undue exertion, whether +mental or physical, one may note the subsequent gastro-intestinal +derangement, including even a coating of the tongue. The slightest +deviation from the usual diet, the most trivial fatigue, a chill of +the body, even a change in the temperature of the food may set loose +the most extreme reactions in the gastro-intestinal tract--motor, +sensory, or secretory. It is not an accident that so often the mucous +diarrhoea, which may have afflicted an excitable child in London for +many months, and which a visit to the seaside, with all its healthy +activities, may seem to have completely cured, relapses within a day +or two of the return to the restricted environment and uninteresting +routine of life in London. The child who was happy and busy and at +peace with himself, at play in the open air, resents the sudden +cessation of all this, and the nervous unrest returns. To attempt +treatment by dietetic restrictions alone is to deal only with a +symptom. The gastro-intestinal reactions are so violent that the +parents are generally voluble on the subject of the many foods which +cannot be taken and the few which are not suspect. To prescribe rigid +tables of diet is to add to the alarm of the mother, and to sustain +her in the belief that the child is in daily danger of being poisoned +by a variety of common articles of diet. Only by lowering the +excitability of the nervous system, by occupying the mind and giving +strength to the child's powers of control can we effectively combat +the hyperaesthesia. If necessary the personnel of the management of +the child will have to be altered. There may be no other way to +achieve certain and rapid improvement in a condition which is causing +grave danger to the child and very genuine distress and suffering to +the parents. A violent reaction to intoxications of all sorts is a +further stigma of nervous instability. Sudden and even inexplicable +rises of temperature are frequent complaints, and the constitutional +effects of even trivial local infections are apt to be +disproportionately great. + +Fatigue is easily induced and is exhibited in all varieties of +activity--mental, physical, or visceral. Mental work may produce +fatigue with extreme readiness even although the quality of the work +may remain of a high standard. To Darwin and to Zola work for more +than three hours daily was an impossibility, and yet their work done +under these restrictions excites all men's admiration. The palpitation +and breathlessness which follows upon trivial exertion, such as +climbing a flight of stairs, is a good example of visceral fatigue. + +Among adult neuropaths we recognise the harm which may be done by +unwise speeches on the part of relatives, or still more on the part of +doctors. A chance word from a doctor or nurse off their guard for the +moment will implant in the minds of many such a person the unyielding +conviction that he or she is suffering from some gastric complaint, +from some cardiac affection, or from some constriction of the bowel. +It may take the united force of many doctors to uproot this +pathological doubt which was implanted so easily and so carelessly. +The medical student is notoriously prone to recognise in himself the +symptoms of ailments which he hears discussed. Little children, too, +are apt to suffer in the same way. How much illness could be avoided +if mothers would cease to erect some single manifestation of +insufficient nervous control into a local disorder which becomes an +object of anxiety to the child and to the whole household. + +Undue liability to fatigue, irritability, instability, lack of +control over the emotions, extreme suggestibility, prompt and +exaggerated reactions to toxins of all sorts, excessive vasomotor +reactions and anomalies of secretion, weakness of the +gastro-intestinal apparatus--these, and many other symptoms, are of +everyday occurrence in the nervous child. To discuss them more fully +would be to pass too far from our nursery studies into a consideration +of psychological medicine. + + + + +CHAPTER XI + +NERVOUSNESS AND PHYSIQUE + + +It has already been said that symptoms of nervousness are often +accompanied by faults in the physical development of the child. The +defects may assume so many forms as to make any attempt at description +very difficult. Nevertheless, certain types of physical defect present +themselves with sufficient frequency, in combination with neurosis, to +merit a detailed description. For example, we recognise a type of +nervous child which is marked by a persistence into later childhood of +certain infantile characteristics of the build and shape of body. +Further, we meet with a group characterised by a special want of tone +in the skeletal muscles, by lordosis, by postural albuminuria, and by +abdominal and intestinal disturbances of various sorts. We recognise +also the rheumatic type of child with a tendency to chorea, and in +contrast to this a type with listlessness, immobility, and katatonia. +Lastly, in a few children, in boys as well as in girls, we may meet +with cases of hysteria.[3] + +[Footnote 3: If we accept as hysterical all symptoms which are +produced by suggestion and which can be removed by suggestion, we may +correctly speak of a physiological hysteria of childhood, which +includes a very large number of the symptoms discussed. The term is +used here in its older more limited sense.] + +(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS + +During the first year or eighteen months of life, the rounded +infantile shape of body persists. The limbs are short and thick, the +cheeks full and rounded, the thorax and pelvis are small, the abdomen +relatively large and full. The great adipose deposit in the +subcutaneous tissue serves as a depôt in which water is stored in +large amounts. In the healthy child of normal development by the end +of the second year a great change has taken place. The shape of the +body has become more like that of an adult in miniature. The limbs +have grown longer and slimmer. The thorax and pelvis have developed so +as to produce relatively a diminution in the size of the abdomen. The +body fat is still considerable, but no longer completely obliterates +the bony prominences of the skeleton. Delay in this change, in this +putting aside of the infantile habit of body, is commonly associated +with a corresponding backwardness in the mental development. Such +children walk late, talk late, learn late to feed themselves, to bite, +and to chew effectively. Watery and fat, they carry with them into +later childhood the infantile susceptibility to catarrhal infections +of the lung, bowel, skin, etc., and they are apt to suffer, in +consequence, from a succession of pyrexial attacks. Nasal catarrh, +bronchitis, otitis media, enteritis, eczema, urticaria papulata, are +apt to follow each other in turn, giving rise in many cases to a +persistent enlargement of the corresponding lymphatic glands. The +effect upon the different tissues of the body of these repeated +infections is very various. We are probably not wrong in attributing +the failure to develop and the persistently infantile appearance to a +prejudicial effect upon the various ductless glands in the body. The +condition is associated with an excessive retention of fluid in the +body, secondary in all probability to alterations in the concentration +and distribution of the saline constituents of the body. A rapid +excretion of salts may be followed by a correspondingly speedy +dehydration of the body, a retention of salts by a sudden increase of +weight. The parathyroid glands are probably closely concerned in +regulating the retention and excretion of salts, and especially of +calcium, a circumstance which becomes of significance when we remember +how frequently rickety changes, tetany, and other convulsive seizures +form part of the clinical picture which we are now considering. While +it is difficult to determine the effect of repeated infections upon +the functions of the endocrine glands, we have clear evidence of the +deleterious influence upon almost all the tissues of the body, the +functioning of which it is more easy to estimate. For example, the +cells of the skin and of the mucous membranes which happen to be +visible to the eye show clear evidence of diminished vitality and +increased vulnerability. Physiological stimuli, incapable of producing +any visible reaction in healthy children, habitually determine widely +spread and persistent inflammatory reactions. For example, the +licking movements of the tongue at the corners of the mouth produce +the little unhealthy fissures which the French call _perlèche_. The +physiological stimulus of the erupting tooth is capable of causing a +painful irritation of the gum, so that the child is said to suffer +from teething, accompanied, it may be, and the association is +significant, by "teething convulsions." The irritation of the urine +produces rawness and excoriation of the skin of the prepuce, contact +with intestinal contents not in themselves very abnormal, an +intractable dermatitis of the buttocks or a persistent diarrhoea and +enteral catarrh. Improvement in the general health, the result of the +cessation for the time being of the recurrent infections, perhaps +consequent upon improved hygienic conditions, always determines the +rapid disappearance of all these accompaniments of the general +diminution of tissue vitality. + +The muscular system and the bones are commonly also involved, so that +rickety changes are often found in these infantile and watery +children. In early childhood the processes of calcification and +decalcification proceed side by side and with great rapidity, and in +health there is always a balance on the side of the constructive +process. In the children whom we are now considering, saturated as +they are, from time to time, with the toxins resulting from repeated +infection, ossification may be so interfered with as to cause +softening and bending, with the evolution of a state of rickets. +Between bone and muscle, too, we find a close relationship. We do not +find powerful muscles with softened bone, nor flabby muscle with +rigid and well-formed bone. + +In the nervous system, the conditions are somewhat different. In skin, +in bone, and in muscle new cell elements are constantly being formed, +and the life of the individual cell is relatively short. In the +nervous system, on the other hand, the individual cells are long +lived. Their life-history may even be coterminous with that of the +individual, and if destroyed they are not replaced. Nevertheless, they +do not escape undamaged in the general disturbance. In a deprivation +of calcium we have, in all probability, the explanation of the +increased irritability of peripheral nerves and of the tendency to +convulsive seizures of all sorts which is a common accompaniment of +the condition. Convulsions, laryngismus stridulus, tetany, or +carpopedal spasm are all frequently met with. In crying, the children +hold their breath to the point of producing extreme cyanosis, ending, +as the spasm relaxes, with a crowing inspiration, which resembles and +yet differs in tone from both the whoop of whooping-cough and the +crowing inspiration of croup. + +Apart, however, from this tendency to convulsive seizures the nervous +system of these children is abnormal. As a rule they are excitable, +and develop late the power to control their emotions. Lagging behind +in physical development and in the capacity to interest themselves in +the pursuits of normal children, their emotional state remains that of +a much younger child. In the infant classes at schools they are +recognised as dullards, learning slowly, speaking badly, and lacking +co-ordination in all muscular movements. + +The clinical picture so depicted is encountered with extreme frequency +among the children of the poor in our large cities. To find a name for +the condition is no easy matter. To call it "rickets" is to place an +undue emphasis upon the bony changes which, though common, are by no +means invariable. Elsewhere I have suggested the name status +catarrhalis, on an analogy with the name status lymphaticus, which in +the post-mortem room is used to describe the secondary overgrowth of +lymphatic tissue which is found in these catarrhal children. In the +present connection it is of interest to us to note how commonly the +nervous system is involved in the general picture and the frequency +both of convulsive disorders and of neuropathy. + +The nervous symptoms of both sorts are to be allayed only by improving +the general hygiene of the child and raising its resistance against +infection. A sufficiency of fresh air and of sunlight, and a +management which encourages independence of action in the child, are +both necessary. The diet is of the first importance. It should be +sufficient, and no more than sufficient, to cover the physiological +needs of the child for food. The majority of these children have +enormous appetites, and excess of food, and especially of carbohydrate +food, plays some part in the production of the disturbance. We must +guard against overfeeding, against want of air and want of exercise, +and against those errors of management described in previous chapters, +which produce the maximum of disturbance in this type of child. + + +(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA + +At an older age, in children from the fifth year onwards, a second +type of physical defect associated with pronounced nervous disturbance +presents itself with some frequency. The body is thin and badly +nourished, and the muscular system especially poorly developed and +very lax in tone. The most striking feature is the extreme lordosis, +accompanied usually by a secondary and compensatory curve in the +cervico-dorsal region, so that the shoulders are rounded, with the +head poked forward. Viewed from in front the abdomen is seen to be +prominent, overhanging the symphysis pubis, while the shoulders have +receded far backwards. The scapulæ have been dragged apart, as though +by the weight of the dependent arms, with eversion of their vertebral +borders and lowering of the points of the shoulders. The position +which they adopt is that into which the body falls when it ceases to +be braced by strong muscular support. The muscular system is here so +weakly developed and so toneless that the posture is determined by the +bony structure and its ligamentous attachments. + +The lordosis resembles the similar deformity which develops in cases +of primary myopathy, when the spinal muscles have undergone complete +atrophy. As in myopathy the movements are very uncertain. The +children are apt to fall heavily when the centre of gravity is +suddenly displaced, because their upright posture is maintained by +balancing the trunk upon the support of the pelvis. The frequency and +severity of the falls which these children suffer is a common +complaint of the mother. The faulty posture is often associated with +slight albuminuria. Its appearance is very capricious, but it is +dependent to a great extent upon the assumption of the erect posture. +There has been much discussion as to its explanation. It has been +argued that the lordosis itself produces the albuminuria by mechanical +compression of the renal vein, and it is said that albuminuria can be +produced, even in the prone position, by placing the child in a +plaster jacket applied so as to maintain the position of lordosis. +Other observers, however, have not obtained this result. It seems most +likely that the albuminuria is due to defective tone in the vasomotor +musculature, comparable in every way to the defective tone in the +muscles of the skeleton. We have often further evidence of vasomotor +weakness. Fainting attacks are so common as to be the rule rather than +the exception. Again, mothers are likely to complain of the child's +pallor and of dark lines under the eyes, especially after exertion or +in the reaction which follows excitement of any sort. As a rule a +blood count will not show any very striking evidence of true anæmia. +The pallor is of vasomotor origin, determined by faults in the +distribution of the blood from vasomotor weakness and not by deficient +blood formation. Circulatory and vasomotor disturbance probably also +accounts for the dyspeptic pains and vomiting which commonly accompany +any emotional excitement, or follow any unusual exertion or fatiguing +experience. Constipation is a common, and mucous diarrhoea an +occasional, symptom. The abdomen is often pigmented. The hands and +feet are usually cold and cyanosed. + +The extreme nervousness of the children is the point upon which most +stress may be laid in the present connection. The association of +albuminuria with neurosis in childhood has been noticed by many +observers. The gastric and intestinal symptoms are especially +characteristic. If the condition of the children is not materially +improved, and if the symptoms, both of the physical defect and of the +nervous disturbance, are not cut short, we may predict that in adult +age their lives will be made miserable by a variety of abdominal +symptoms dependent both on the vasomotor disturbance and upon the +accompanying neurosis. Now that surgery forms so large a part of our +therapeutic proceedings, they may not reach middle life without being +submitted to one or more surgical operations. With good management +both on the physical side and on the moral or psychological side they +can be made into strong and useful members of society. + +The treatment of these cases may be summed up as follows: + +_(a)_ We must search for any source of infection, a source which is +often to be found in the condition of the tonsils. Enucleation may +then be indicated as the first step in treatment. + +_(b)_ Massage and gymnastic exercises calculated to improve the +muscular tone, while every effort is made to secure for the child as +perfect hygiene in the environment as possible. + +_(c)_ The stimulating effect of cold douches is often very evident in +improving the vasomotor tone. These children, however, will not stand +well the abstraction of heat from their thin and chilly little bodies, +so that it is a good plan before the colder douche to immerse the +child in a hot bath and to return again to the bath momentarily +afterwards. With these precautions children will often enjoy a cold +spray, the temperature of which may be constantly lowered as they +become used to it. Prolonged hot bathing has a correspondingly +prejudicial effect. + +_(d)_ We must be on the watch to prevent the development of further +postural deformities, such as scoliosis. If a child of strong muscular +tone and good physique habitually adopts some posture, curled up, it +may be, in some favourite easy-chair, there is little likelihood that +its constant assumption will produce deformity. When the muscular +system is lax and weak, on the other hand, deformity such as scoliosis +is very readily caused. It is important, for example, to see that the +child does not habitually incline to one side in reading or writing. +When there is little energy for free and energetic play the children +are apt to become great bookworms. If there is shortsightedness, the +dangers are correspondingly increased. A special chair may be made +with a well-fitting back and the seat a little tilted upwards so as to +throw the child's trunk on to the support of the back. Lastly, a desk, +the height of which can be regulated at will, can be swung into the +proper position. The child, sitting straight and square, with the +weight supported by the foot-rest and back as well as by the seat of +the chair, should be taught to write with an upright hand, avoiding +the slope which leads to sitting sideways with the left shoulder +lowered. + +(e) Malt extract, cod liver oil, Parrish's food, and other tonics may +be of undoubted service. + + +(3) RHEUMATISM AND CHOREA + +It is certain that there is a close association between rheumatism in +childhood and the common nervous affection known as chorea. We are +still ignorant of the precise nature of the infection which we know as +rheumatism. There is much to suggest that in rheumatism we have to +deal only with a further stage in those catarrhal infections to which +so much infantile ill-health is to be attributed, and that +endocarditis and arthritis, when they arise, signalise the entry of +these catarrhal, non-pyogenic organisms into the blood stream, +overcoming at last the barrier of lymphoid tissue which has +hypertrophied to oppose their passage. Certainly the connection of +rheumatism with catarrhal infections of the mucous membranes and +adenoid enlargements of all sorts is a close one. Whatever its +nature, the rheumatic infection in childhood is more lasting and +chronic than in adult life. Rheumatism in childhood is not manifested +by acute and short-lived attacks of great severity so much as by a +long-continued succession of symptoms of a subacute nature, a +transient arthritis, perhaps, succeeding an attack of sore throat with +torticollis, to be followed by carditis, to be followed again by +another attack of tonsillitis. And so the cycle of symptoms revolves. +In most cases the child grows thin and weak; in most cases he becomes +restless, irritable, and unhappy; often there is definite chorea. Of +this cerebral irritability chorea is the expression. In adults, chorea +is perhaps more obviously associated with mental stress of all sorts +and with states of excitement and agitation. In the case of little +children it is often only the mother who really appreciates how +radical an alteration the child's whole nature has undergone, and how +great the element of nervous overstrain has been before the chorea has +appeared. + +Of the treatment of chorea there is no need to speak. It is purely +symptomatic. Isolation, best perhaps away from home, as might be +expected, gives the best results. If there are pronounced rheumatic +symptoms, the salicylates will be needed; if there is anæmia, arsenic +and iron; if there is sleeplessness and great restlessness, bromides +or chloral. Hypnotism is often almost instantly successful, but, apart +from hypnosis, curative suggestions proceeding from the attendants +form the principal means at our disposal. + + +(4) EXHAUSTION AND KATATONIA + +A large number of children, in convalescence from infective disorders, +when the nutrition of the body has fallen to a low ebb, show as +evidence of cerebral exhaustion a group of symptoms which in a sense +are the reverse of those which characterise cerebral irritation and +chorea. The healthy child is a creature of free movement. The children +we are now considering will sit for a long time motionless. The +expression of their faces is fixed, immobile, and melancholy. If the +arm or leg is raised it will be held thus outstretched without any +attempt to restore it to a more natural position of rest for minutes +at a time. The posture and expression remind us at once of the +katatonia which is symptomatic of dementia præcox and other stuporose +and melancholiac conditions in adult life. Symptoms of this sort are +especially common in children with intestinal and alimentary +disturbances of great chronicity. + +The symptom is so frequently met with that it is strange that it +should have attracted so little attention as compared with the +contrasting condition of chorea. And yet it is of more serious +significance, more difficult to overcome, and with a greater danger +that permanent symptoms of neurasthenia will result. In early +childhood a careful dietetic régime, suitable hygienic surroundings, +and a stimulating psychical atmosphere will often effect great +improvement. As in chorea, however, relapses are frequent, and there +are cases which for some unexplained reason are peculiarly resistant +to all remedial influences. + + +(5) HYSTERIA + +In hysteria, in contrast to the types previously described, the +infective element may be completely absent. Except in some special +features of minor importance the symptoms of hysteria do not differ +from those of adults, and, as in adult age, the condition of hysteria +may be present although the physical development may be perfect. We +cannot here speak of any physical characteristics which are associated +with the nervous symptoms. + +The third or fourth year represents the age limit, below which +hysterical symptoms do not appear. Thereafter they may be occasionally +met with, with increasing frequency. At first, in the earlier years of +childhood, there is no preponderance in the female sex. As puberty +approaches, girls suffer more than boys. + +It may be said to be characteristic of hysteria in childhood that its +symptoms are less complex and varied than in adult life. The naive +imagination of the child is content with some single symptom, and is +less apt to meet the physician half-way when he looks for the +so-called stigmata. Similarly mono-symptomatic hysteria is +characteristic of oases occurring in the uneducated or peasant class. +In children, hysterical pain, hysterical contractures or palsies, +mutism, and aphonia are the most usual symptoms. Hysterical deafness, +blindness, and dysphagia are manifestations of great rarity in +childhood. + + + + +CHAPTER XII + +THE NERVOUS CHILD IN SICKNESS + + +In time of sickness the management of the nervous child becomes very +difficult. Restlessness and opposition may reach such a pitch that it +may be almost impossible to confine the patient to bed or to carry out +the simplest treatment. Sometimes days may elapse before the +sick-nurse who is installed to take the place of the child's usual +attendant is able to approach the cot or do any service to the child +without provoking a paroxysm of screaming. In such a case any +systematic examination is often out of the question, with the result +that the diagnosis may be delayed or rendered impossible. There is +only one reassuring feature of a situation, which arises only in +nurseries in which the management of the children is at fault; the +doctor has learned from experience that this pronounced opposition of +the child to himself, to the nurse, and even to the mother, is of +itself a reassuring sign, indicating, as a rule, that the condition is +not one of grave danger or extreme severity. When the child is more +seriously ill, opposition almost always disappears, and the child lies +before us limp and passive. Only with approaching recovery or +convalescence does his spirit return and renewed opposition show +itself. + +Extreme nervousness in childhood carries with it a certain liability +towards what is known as "delicacy of constitution." The sensitiveness +of the children is so great that they react with striking symptoms to +disturbances so trivial that they would hardly incommode the child of +more stable nervous constitution. For example, a simple cold in the +head, or a sore throat, may cause a convulsion or a condition of +nervous irritability which may even arouse the suspicion that +meningitis is present. Or, again, a little pharyngeal irritation which +would ordinarily be incapable of disturbing sleep may be sufficient to +keep the child wide awake all night with persistent and violent +coughing. The little irritating papules of nettlerash from which many +children suffer are commonly disregarded by busy, happy children +during the day, and even at night hardly suffice to cause disturbance. +The nervous child, on the other hand, will scratch them again and +again till they bleed, tearing at them with his nails, and making deep +and painful sores. + +The temperature is commonly unstable and readily elevated. Moreover, +feverishness from whatever cause is often accompanied by an active +delirium, which is apt to occasion unnecessary alarm. This symptom of +delirium is always a manifestation of an excitable temperament. I +remember being called to see a young woman who was thought to be +suffering from acute mania. Examination showed that she was suffering +from pneumonia in the early stages. It was only later that we +discovered that she had always been of an unstable nervous +temperament, and had been in an asylum some years before. Those of us +who are fortunate in possessing a placid temperament and have +developed a high degree of self-control are not likely to show +delirium as a prominent symptom should we fall ill with fever; just as +we should not struggle and scream too violently when we "come round" +from having gas at the dentist's. Looked at from this point of view, +it is natural for all children to become delirious readily, and this +tendency is peculiarly marked in those who are unduly nervous. + +As a consequence of this extreme sensitiveness, the nervous child is +likely to suffer more than others from a succession of comparatively +trifling ailments and disturbances. The delicacy of the child has, in +this sense, a real existence, and is not confined to the imagination +of over-anxious and apprehensive parents. No doubt the nervous mother +of an only child does worry unnecessarily, and is far too prone to +feed her fears by the daily use of the thermometer or the +weighing-machine; but her friends who are happy in the possession of +numerous and placid children are not justified in laying the whole +blame upon her too great solicitude. Children who are members of large +families, whose nervous systems have been strengthened by contact with +their brothers and sisters, are not habitually upset by trifles, and +suffer even serious illnesses with symptoms of less severity. Nervous +children, and only children, on the other hand, show the opposite +extreme. Nevertheless, the mother of a nervous and delicate child--a +child, that is to say, who, even if he is not permanently an invalid, +nevertheless never seems quite well and lacks the robustness of other +children--should realise clearly how much of this sensitiveness is due +to the atmosphere of unrest and too great solicitude which surrounds +him. It is a matter of universal experience that excess of care for +only children has a depressing influence which affects their +character, their physical constitution, and their entire vitality. At +all costs we must hide our own anxieties from the child, and we must +treat his illnesses in as matter-of-fact a way as possible. + +When illness comes, his daily routine should be interrupted as little +as possible. In dealing with nervous children, it is often better to +lay aside treatment altogether rather than to carry out a variety of +therapeutic procedures which have the effect of concentrating the +child's mind upon his symptoms. When we grown-up people are sick, we +often find a great deal of comfort in submitting ourselves to some +form of treatment. We have great faith, we say, in this remedy or in +that. It is _our_ remedy, a _nostrum_. The physician knows well that +the opportunities which are presented to him of intervening +effectually to cut short the processes of disease by the use of +specific cures are not very numerous, and that often enough the +justification for his prescription is the soothing effect which it +may exercise upon the mind of the patient, who, believing either in +the physician or in his remedy, finds confidence and patience till +recovery ensues. As a rule this form of consolation is denied to +little children. They have no belief in the efficacy of the remedies +which are applied with such vigour and persistence. Indeed, it is not +the child, but his anxious mother, who finds comfort in the thought +that everything possible has been done. Therefore, a prescription must +be written and changed almost daily, the child's chest must be +anointed with oil, and the air of the sick-room made heavy with some +aromatic substance for inhalation, and all this when the disturbance +is of itself unimportant, and owes its severity only to the undue +sensitiveness of the child's nervous system. + +The very name of illness should be banished from such nurseries. +Everything should be done to reassure the child and to make light of +his symptoms, and we can keep the most scrupulous watch over his +health without allowing him to perceive at all that our eye is on him. +With older children the evil results of suggestions, unconsciously +conveyed to them by the apprehension of their parents, become very +obvious. The visit of the doctor, to whom in the child's hearing all +the symptoms are related, is often followed by an aggravation which is +apt to be attributed to his well-meant prescription. The harm done by +examinations, which are specially calculated to appeal to the child's +imagination, as, for instance, an X-ray examination, is often clearly +apparent. I remember a schoolboy of thirteen who was sent to me +because he had constantly complained of severe abdominal pain. He was +a nervous child with a habit spasm, the son of a highly neurotic +father and an overanxious mother. An X-ray examination was made, but +showed nothing amiss. The child's interest and preoccupation in the +examination was painfully obvious. That night his restraint broke down +altogether, and he screamed with pain, declaring that it had become +insupportable. Younger children, less imaginative but equally +perverse, noticing how anxiously their mothers view their symptoms, +will often make complaint merely to attract attention and to excite +expressions of pity or condolence. Sometimes they will enforce their +will by an appeal to their symptoms. I have had a little patient of no +more than thirteen months of age who suffered severely and for a long +time from eczema, and who in this way used his affliction to ensure +that he got his own way. If he was not given what he wanted +immediately he would fall to scratching, with an expression upon his +face which could not be mistaken. To him, poor child, the grown-up +people around seemed possessed of but one desire--to stop his +scratching; and he had learnt that if he showed himself determined to +scratch they would give way on every other point. + +The ill-effects of departing too readily from ordinary nursery routine +on account of a little illness, and of adopting straightway a variety +of measures of treatment, is well shown in cases of asthma in +children. The asthmatic child is almost always of a highly nervous +temperament, and often passionate and ungovernable. Often the most +effective treatment of an attack, which usually comes on some hours +after going to bed, is to make little of it, to talk naturally and +calmly to the child, to turn on the light, and to allow him, if he +will, to busy himself with toys or books. To be seized with panic, to +send post-haste for the doctor, to carry the patient to the open +window, to burn strong-smelling vapours, and so forth, not only is apt +to prolong the nervous spasm on this occasion, but makes it likely +that a strong impression will be left in his mind which by +auto-suggestion will provoke another attack shortly. With nervous +children a seeming neglect is the best treatment of all trivial +disorders. Meanwhile we can redouble our efforts to remedy defects in +management, and to obtain an environment which will gradually lower +the heightened nervous irritability. + +When the illness is of a more serious nature, as has been said, the +restlessness as a rule promptly disappears. In each case it must be +decided whether it is best for the child to be nursed by his mother +and his own nurse, or by a sick-nurse. In the latter event the +ordinary nurse and the mother should absent themselves from the +sick-room as much as possible. Often the firm routine of the hospital +nurse is all that is wanted to obtain rest. Less often, the child will +be quiet with his own nurse, and quite unmanageable with a stranger. + +There is, however, another side to the question. The relation of +neurosis in childhood to infection of the body is complex. I have said +that with the nervous child a trivial infection may produce symptoms +disproportionately severe. Persistent and serious infection, however, +is capable of producing nervous symptoms even in children who were not +before nervous, and we must recognise that prolonged infection makes a +favourable soil for neuroses of all sorts. The frequency with which +St. Vitus's dance accompanies rheumatism in childhood forms a good +example of this tendency. The child who, from time to time, complains +of the transient joint pains which are called "growing pains," and who +is found by the doctor to be suffering from subacute rheumatism, is +commonly restless, fretful, and nervous. Appetite, memory, and the +power of sustained attention become impaired. Often there is excessive +emotional display, with, perhaps, unexplained bursts of weeping. The +child is readily frightened, and when sooner or later the restless, +jerky movements of St. Vitus's dance appear, the usual explanation is +that some shock has been experienced, that the child has seen a street +accident, has been alarmed by a big dog jumping on her, or by a man +who followed her--shocks which would have been incapable of causing +disturbance, and which would have passed almost unappreciated had not +the soil been prepared by the persistent rheumatic infection. + +The management of the nervous child whose physical health remains +comparatively good is difficult enough, but these difficulties are +increased many times when the physical health seriously fails. To +steer a steady course which shall avoid neglecting what is dangerous +if neglected, and overemphasising what is dangerous if +over-emphasised, calls for a great deal of wisdom on the part both of +the mother and her doctor. + + + + +CHAPTER XIII + +NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS + + +In this chapter I approach with diffidence a subject which is rightly +enough occupying a great deal of attention at the present time: the +instruction of our children in the nature, meaning, and purpose of +sexual processes. It is a subject filled with difficulties. Every +parent would wish to avoid offending the sense of modesty which is the +possession of every well-trained child, and finds it difficult to +escape the feeling that discussion on such matters may do more harm +than good. There is certainly some risk at the present time that, +putting reticence on one side, we may be carried too far in the +opposite direction. The evils which result from keeping children in +ignorance are well appreciated. We have yet to determine the effect +upon them of the very frank and free exposure of the subject which is +recommended by many modern writers. Nevertheless, it must be granted +that it is not right to allow the boy or girl to approach adolescence +without some knowledge of sex and the processes of reproduction. If +nothing is said on such subjects, which in the nature of things are +bound to excite a lively interest and curiosity in the minds of older +children, evil results are apt to follow. Because parents have never +mentioned these subjects to their child, they must not conclude that +he is ignorant of all knowledge concerning them. It is not unlikely +that the question has often occupied his thoughts, and that his +speculations have led him to conclusions which are, on the whole, +true, although perhaps incorrect in matters of detail. Most children, +unable to ask their mother or father direct questions upon matters +which they feel instinctively are taboo, have pieced together, from +their reading and observation, a faulty theory of sexual life. The +pursuit of such knowledge, in secret, is not a healthy occupation for +the child. His parents' silence has given him the feeling that the +unexplored land is forbidden ground. In satisfying his curiosity he is +most certainly fulfilling an uncontrollable impulse, but he has been +forced to be secretive, and to look upon the information he has +acquired as a guilty secret. So far even the best of children will go +upon, the dangerous path. If training has been good, and if the child +has responded well to it, he will go no further. Though he can hardly +be expected to refrain from constructing theories and from testing +them in the light of any chance information which may come his way, he +will instinctively feel that the subject is one best left alone. He +will not talk of it with other boys--not even with those who are older +than himself and whose superior knowledge in all other matters he is +accustomed to respect. We need not be surprised, however, that the +majority of children do not attain to this high standard of conduct, +and that the interest and excitement of exploring the unknown and the +forbidden proves too great. Children will consult with each other +about such matters, and knowledge of evil may spread rapidly from the +older to the younger. In some schools, as is well known, there may +grow up with deplorable facility an unhealthy interest in sexual +matters. On the surface of school life all may seem fair enough, but +beneath, hidden from all recognised authority, lies much that is +unspeakable. If the boy has not been taught to have clean thoughts +upon matters which are essentially clean, if he has not learned to +know evil that he may avoid it, he may not escape great harm. The +fault in us which kept him in ignorance will recoil upon our own +heads. He will maintain the barrier which was erected in the first +place by our own unhappy reticence, and we may find it a hard task to +penetrate behind it and prevent his constant return to secret thoughts +and imaginings or secret habits and practices. Certain physiological +processes come to have for him an unclean flavour which is yet +perniciously attractive. He knows little of the real meaning of sexual +processes or of the great purpose for which they are designed. It is +only that an unhealthy interest becomes attached to all subjects which +are scrupulously avoided in general conversation. In secret he +develops a wrong attitude to all these matters. + +Oliver Wendell Holmes[4] tells us that in religion certain words and +ideas become "polarised," that is to say, charged with forces of +powerful suggestion, and must be "depolarised." + +[Footnote 4: _The Professor at the Breakfast Table_, Oliver Wendell +Holmes.] + + * * * * * + +"I don't know what you mean by 'depolarising' an idea, said the +divinity-student. + +"I will tell you, I said. When a given symbol which represents a +thought has lain for a certain length of time in the mind, it +undergoes a change like that which rest in a certain position gives to +iron. It becomes magnetic in its relations--it is traversed by strange +forces which did not belong to it. The word, and consequently the idea +it represents, is polarised. + +"The religious currency of mankind, in thought, in speech, and in +print, consists entirely of polarised words. Borrow one of these from +another language and religion, and you will find it leaves all its +magnetism behind it. Take that famous word, O'm, of the Hindoo +mythology. Even a priest cannot pronounce it without sin; and a holy +Pundit would shut his ears and run away from you in horror, if you +should say it aloud. What do you care for O'm? If you wanted to get +the Pundit to look at his religion fairly, you must first depolarise +this and all similar words for him. The argument for and against new +translations of the Bible really turns on this. Scepticism is afraid +to trust its truths in depolarised words, and so cries out against a +new translation. I think, myself, if every idea our Book contains +could be shelled out of its old symbol and put into a new, clean, +unmagnetic word, we should have some chance of reading it as +philosophers, or wisdom-lovers, ought to read it--which we do not and +cannot now, any more than a Hindoo can read the 'Gayatri' as a fair +man and lover of truth should do." + + * * * * * + +Now in the minds of many boys and some girls certain words and ideas +connected with certain physiological processes become polarised. It is +the parents' duty to depolarise them. It is a task which cannot well +be deputed to others; nor can much help be derived from books, though +many have been written with the object of initiating children into the +mysteries of sex. No one but a parent is likely to be on sufficiently +intimate terms with the child to enable the subject to be approached +without restraint or awkwardness, and no book can adapt itself to the +varying needs of individual children. An exposition in cold print, or +a single formal lecture on the subject, is apt to do more harm than +good. I have seen instructions to parents to deliver themselves of set +speeches, examples of which are given, which seem to me well +calculated to repel and frighten the nervous child. Still more +dangerous is the advice to make sexual hygiene a subject for class +study. The task requires that parents should be upon very intimate +terms with their children, and on suitable occasions, when this +feeling of intimacy is strong, children should be encouraged to speak +freely and to ask for explanations. By a judicious use of such +opportunities piece by piece the whole may be unfolded. In order that +the child may approach the subject in the proper spirit we may +stimulate interest by a few lessons in Natural History. A child of +eight or ten years of age is not too young to learn a little of the +outlines of anatomy and physiology. If he is told a few bald facts +about the skeleton, about the circulation and the processes of +digestion such as any parent can teach at the cost of a few hours' +study of a handbook, this will lead naturally enough, in later +lessons, to a similar talk upon the excretory organs, reproduction, +and the anatomy and processes of sex, suitable to the individual. To +achieve "depolarisation," there is nothing more efficacious than the +frankness and explicitness of scientific statement, however +elementary. Later a little knowledge of Botany and Zoology will enable +a parent to sketch briefly the outlines of fertilisation and +reproduction. The child may grasp the conception that the life of all +individual plants and animals is directed towards the single aim of +continuing the species. He can be told how the bee carries the male +pollen to the female flower, how all living things habitually +conjugate, the lowest in the scale of development as well as the +highest, and how the fertilised egg becomes the embryo which is +hatched by the mother or born of her. As the child grows older and +understands more and more of these natural processes an opportunity +can be used to make the presentation of the subject more personal. He +can be told that during childhood his own sexual processes have been +undeveloped, but that as he grows older they will awake. That with +their awakening in adolescence new temptations to self-indulgence in +thought or action may assail him, but that these temptations are +delayed by the wisdom of Nature until his understanding has grown and +his man's strength of character has developed. A high ideal of purity +should be set before boy and girl alike, and the conception of sex +from the beginning should be associated in their minds with the high +purpose to which some day it may be put. Before the boy goes to a +boarding-school he should have imbibed from his father the desire for +moral cleanliness, the knowledge of good and of evil, and a cordial +dislike for everything that is sensual, self-indulgent, or nasty. +Talks on such subjects should be very infrequent, but I believe that, +if "depolarisation" is to be achieved, they must be repeated every now +and then during later childhood and in adolescence. To attempt to +impart all this interesting information in a single constrained and +awkward interview is to court failure, or at least to run the risk +that the explanation is not fully understood, so that the child is +mystified, or even offended in his sense of propriety. + +I have dwelt at some length upon this question of sex education, +because it is one of especial difficulty when we have to deal with a +child of nervous inheritance, or with a child in whom symptoms of +neurosis have developed in a faulty home environment. Misconduct in +sexual matters is a sign of deficient nervous and moral control, and +when the conduct in other respects is ill-regulated, the development +of sexual processes must be watched with some anxiety. There are those +who see a still more intimate relationship between errors of conduct +or symptoms of neurosis in childhood and the sexual instincts. + +It is perhaps necessary here briefly to refer to the teaching of +Sigmund Freud of Vienna, because his views have attracted a great deal +of attention in this country and have become familiar to a great part +of the reading public. Freud believes that the origin of many abnormal +mental states and of the disturbances of conduct which are dependent +upon them is to be traced back to forgotten experiences, the +recollection of which has faded from the conscious mind, but which are +still capable of exerting an indirect influence. He regards the +process of forgetting, not as merely a passive fading of mental +impressions, but as an active process of repression, by which the +experience, and especially the unpleasant experience, is thrust and +kept out of consciousness. There thus arises a mental conflict between +the forces of repression and the forces which tend to obtrude the +recollection into consciousness, and at times the energy engendered in +this conflict escapes from the censorship of the repressing forces and +finds vent in the production of abnormal mental states or disorders of +conduct. Thus to take a simple example, a business man who has had a +trying day at the office, on returning home in the evening may succeed +in thrusting out of his consciousness the thought of his +disappointments and worries, yet the disturbance in his mind may show +itself in quarrels with his wife or complaints of the quality of the +cooking at dinner. + +Freud has called attention to the part which the suppressed and +long-forgotten experiences of early childhood play in the production +of neuroses of all sorts at a later date, and he has laid especial +emphasis on sexual experiences as peculiarly fruitful causes of such +disturbances. Those who have embraced Freud's teaching have gone even +farther than he in this direction, and by psycho-analysis--that is to +say, by attempting in intimate conversation to arouse the dormant +memory and lay bare the buried complex, the suppression of which has +produced the conflict in the mind of the sufferer--will seldom fail to +discover the influence of sexual forces and sexual attractions which, +while capable of causing disorders of mind and of conduct, show +themselves only obscurely and indirectly, as, for example, in dreams +or in symbolic form. + +So far as the nervous disorders of children are concerned, much that +is written to-day upon the influence of repressed sexual experiences +may be dismissed as grotesque and untrue. The conclusions to which the +psycho-analyst is habitually led, and which he puts forward with such +confidence, can be convincing only to those who have replaced the +study of childhood by the study of the writings of Freud and his +school. Thus it is common enough to find a mother complaining that her +child of two or three years of age is bitterly jealous of the new baby +who has come to share with him his mother's love and attention. +According to the views of Freud, we are to recognise in this jealousy +an exhibition of the sexual instincts of the older child, who scents a +possible rival for the affections of his mother. Even if we give to +the term sexual the widest possible meaning, it is difficult for a +close observer of children to detect any truth in this conclusion. The +behaviour of the older child to the newly born will be determined +mainly by the attitude adopted by the grown-up persons around him and +by the unconscious suggestions which his impressionable mind receives +from them. If the mother is fearful of what may happen, and refuses to +leave the children alone, she will find it hard to hide from the older +child her conviction that danger is to be apprehended from him. If +this suggestion acts upon his mind, and if the reputation that he is +jealous of the new baby becomes attached to him, he will assuredly not +fail to act up to it, and her daily conduct will appear to prove the +justness of his mother's apprehension. Fortunately, mothers are +commonly able to divest themselves of such fears as these. The older +child is brought freely to the baby to admire him, to bestow caresses +on him, and to speak to him in the very tones of his elders. In a few +days his reputation is established, that he is "so fond of the baby," +and to this reputation too he faithfully conforms. We have seen in an +earlier chapter that constantly and ostentatiously to oppose a child's +will is to produce a counter-opposition which because of its +persistence and vigour appears to have behind it the strongest +possible concentration of mind and power of will. Yet if we cease to +oppose, the counter-opposition which appeared so formidable at once +dissolves, and the difficulty is at an end. We took as an example the +child's apparent determination to approach as near as possible to the +fire, the one place in the room which our fear of accident forbids +him. The difficulty with the new baby is but another example of the +same tendency. If he does not know that the ground is forbidden, if we +do not concentrate his attention on the prohibition, he will show no +particular desire to approach it. His apparent jealousy of his little +brother is the result not of the rivalry of sex, but of bad +management. + +Again, it is occasionally a subject of complaint that children will +apparently dislike their father, that they will shrink from him or +burst into tears whenever he approaches them. There is no need to see +in this the child's jealousy of the father as a rival in the +affections of his mother, which is the explanation proffered by the +school of Freud. Every action and every occupation of the child during +the whole day can be made a pleasure or a pain to him, according to +the attitude of his nurse and mother towards it. Eating and drinking +should be pleasant and are normally pleasant. The same forces which +are sufficient to make every meal-time a signal for struggling and +tears, are sufficient to produce this dislike, apparently so +invincible, to the father of his being. + +Although the nervous troubles of infancy are not commonly due, as +Freud and his numerous followers would have us believe, to suppressed +sexual desires or experiences, it is clear that in the sensitive mind +of the child the reception of a severe shock may have effects long +after the memory of it has disappeared from consciousness. In a +medical journal there was recently recounted the case of an officer of +the R.A.M.C. who all his life had suffered from claustrophobia--the +fear of being shut up in a closed space. By skilful questioning, the +remembrance of a terrifying incident in his childhood was regained. As +a child of five he had been shut in a passage in a strange house by +the accidental banging to of a door, unable to escape from the +attentions of a growling dog. A complete cure was said to follow upon +the discovery that in this incident lay the origin of the phobia. +Nevertheless, observation would lead me to lay the greater stress not +upon any one particular shocking or terrifying experience, but upon +the attitude of parents and nurses in focusing the child's attention +upon the danger, and in sapping his confidence by showing their own +apprehensions and communicating them to him. + +As a method of treatment for neuroses of childhood, psycho-analysis is +not only unsuccessful, it has dangers and produces ill effects which +far outweigh any advantage which may be gained from it. + +There can be no doubt that Freud has exaggerated the part which sexual +impulses play in causing neurosis. It will be sufficient for us to +recognise that for the nervous child the sexual life has especial +dangers, and we should redouble our efforts to prevent his ideas on +the subject becoming "polarised." For the child whose environment has +been well regulated and who has developed strength of character, +self-control, and self-respect, there need be no fear. + + + + +CHAPTER XIV + +THE NERVOUS CHILD AND SCHOOL + + +At the onset of puberty childhood comes to an end, and the period of +adolescence begins. Into these further stages of development it is not +proposed to enter, but it may be well to consider a question which is +apt to present itself for answer at this period: "Should the boy, or +girl, of nervous temperament, or whose development up to this point +has been accompanied by symptoms of nervous disorder, be sent to a +boarding-school?" So long as the child remains at home the home +environment is the force which alone is concerned in moulding his +character. We have seen how plastic the young child is, how imitative, +how suggestible, how prone to form habits good or bad. The diversity +of type shown by the homes is reflected in the diversity of character +and conduct exhibited by the children. The home is the culture medium, +and in no two homes is its composition the same. For each child home +influence remains to a great extent unchanged, and in great part +unchangeable. Its action upon the child is constant and long +sustained. Hence, it is not surprising that the growth of his +character and powers is commonly unequal. At one point we may find a +good crop of virtues, at another a barren tract; and the home +influences which have ripened the one and blighted the other are +calculated by the lapse of time to increase the contrast rather than +to diminish it. + +I suppose it is for this reason that the custom of sending children to +boarding-schools has so firm a hold among us. The boarding-school +forms an environment selected to correct the inequalities which result +from the special action upon the child of individual homes. The life +of a boy in one of our large public schools is well calculated to act +as a corrective in this way not only by reason of its ordered routine +and discipline, but still more because it is affected, perhaps for the +first time, by the strong force of public opinion. It is the strength +of this public opinion which gives to our public schools their +peculiar character and produces their peculiar effects. That which the +schoolboy most despises is what he calls "Bad Form," and he bows down +and worships an idol he himself has set up, the name of which is "Good +Form." Public opinion forms the code of morals observed in the school. +The standard set is commonly not so high as to be very difficult of +attainment. It demands many good qualities. To lie, to sneak, to tell +tales, to bully, to "put on side," are bad form. In some respects the +definition of what is virtuous may be a little hazy. Thus it may be +wrong to cheat to gain a prize, but to copy from one's neighbour only +so much as will enable one to pass muster and escape condemnation is +no great sin. In short, good form demands that a boy should have all +the social virtues: that he should be a good fellow, easy to live +with, and possessed of a high sense of public spirit--good qualities +certainly, though perhaps not those which help to make the reformers +or martyrs of this world. + +The school life is the life of the herd, and to be successful in it +the boy must mingle with the herd, not break from it or shun it. Good +form--if we came to analyse the conception that underlies it--consists +only in a close approximation to the standard pattern; bad form, in +any deviation from it. It is this similarity of type and community of +ideals which makes it so easy for most public-school boys to get on +well with one another. When in after life they are thrown among a set +of men who know nothing of their conception of good form, and whose +training has been on completely different lines, there may be a +corresponding difficulty. + +Now what is true of public-school life is of course also true of the +larger life after schooldays are over for which all education is a +preparation. These qualities of sociability and good sportsmanship +will stand a man in good stead throughout life. Even the most ardent +and active spirit will benefit by being subjected for some years to +this steady pressure of public opinion. The most part will learn from +it good sense, consideration for others, and self-control. As they +pass from the lower forms to the higher in the school they will learn +too to support authority without doing injustice, and to bring the +weight of public opinion to bear upon others. And to all this +training many a man owes his happiness in after life--a happiness +which he could not have secured if his character had been moulded only +by the environment of his home, or by the home in combination with the +less-powerful corrective of a day school. For the nervous child the +passage from home to school life may involve considerable mental +strain. He may be morbidly self-conscious and timid, or, unknown to +himself--because he has as yet no power of self-analysis and has no +opportunities of comparing himself with others--he may have developed +certain eccentricities. In most cases the plunge into school life will +be taken well enough; in a few the little vessel will not right +itself, and proves permanently unseaworthy. No doubt as a rule a +private school will have preceded the public school, and this +gradation should make the entrance to the public school a lesser +ordeal. But it often happens that it is just in the case of the +nervous child that this intermediate stage has been omitted, and that +his thirteenth birthday finds him still in the home circle. + +If the boy's father has first-hand knowledge of life in the lower +forms of public schools, his experience may enable him to form some +estimate of the effect of school life upon the nervous system of his +son. It is when parents or guardians have no such experience of their +own to guide them that mistakes are most liable to be made. I can +myself remember the unhappy state of some solitary and eccentric +schoolfellows of mine who aroused the resentment of "the Herd" by +their behaviour or opinions. If it is clear that the boy has a +peculiar temperament and is likely to suffer in this way, some _via +media_ must be found. The home has failed so that he must leave home +and come under the influence of some one who understands the nature of +the difficulty and can adapt the boy to school life. A change of +environment of this sort as a preliminary to the public school is +often all that is needed. If his age permits, every effort should be +made in this way to obtain for the nervous child who has developed +peculiarities or faults the benefits of a public-school education. + +Some types of nervous children will show immediate improvement when +they go to school. The boy who is passionate and disobedient, and +whose parents cannot control him, is best at school. Boys who, from +being much with grown-up people, have become too precocious and have +acquired the habits and tastes of their elders, will dislike school at +first, but it will do them good. Their fault shows that they are quick +to learn and sensitive to the influences of others, and they will soon +adapt themselves to their new surroundings. Boys who are dreamy and +imaginative, who early adopt a "specialist" attitude towards life, +who, however ignorant they may be of everything else, cultivate a +reputation for omniscience in some particular subject, such as +Egyptology, astronomy, or the construction of battleships, are usually +nervous boys whose symptoms will disappear at school. Where undue +timidity, phobia, or habit spasm is present, the question is more +difficult to decide. Every individual case must be studied as a whole, +and our object should be not unnecessarily to deprive the boy of the +wholesome training of public-school life. + +There are parents who from sheer ignorance add to the difficulties +which the boy encounters in going to school. Failure to appreciate +very small points may cause unnecessary suffering. To be the only boy +in the school to wear combinations is not a distinction that any new +boy craves, however strong his nerves may be. A friend of mine still +relates with feeling how, twenty years ago, he arrived at school with +shirts which _buttoned_ at the neck! At night when every one else in +the dormitory was asleep he sat for hours on his bed, miserable beyond +words, removing the buttons and doing his best in the dark to bore +buttonholes which would admit what every other boy in the school +had--a collar stud. + +With girls perhaps this question of fitness for school life does not +arise in so urgent a way. Girls are usually older when they go to +school, and girls' schools are perhaps less terrifying and more like +home. There is, however, one important point which should be borne in +mind. The date of the onset of puberty varies much in both sexes. If +the boy grows to a great hulking fellow at fourteen, and even displays +a desire secretly to borrow his father's razor, he is at no particular +disadvantage as compared with his fellows. He is so much bigger and +stronger than the others that he may thereby early enjoy the +distinction of playing at "big side," or of getting a place in the +school Eleven. He is probably much envied by those of the same age +who, with the aid of their youthful aspect, can still occasionally +extract compensation by inducing the railway company to let them +travel to school at half fare. But with girls it is different. Many at +fourteen or fifteen are children still; some are grown up, with the +tastes, feelings, and attraction of maturity. Those who have developed +fastest are often, for that very reason, kept backward in school +learning. Often they are nervously the least stable. Now that large +schools for girls on the model of our public schools are become the +fashion, such precociously developed and nervously unstable girls are +apt to find themselves in the very uncongenial society of little girls +of twelve or thirteen. The elder girls commonly hold aloof, while +mistresses are apt to view this precocious development with +disapproval, and to attempt to retard what cannot be retarded by +insisting that the young woman has remained a child. I remember being +called in consultation by a surgeon who had been asked to operate for +appendicitis upon a girl of fourteen. I found a tall, well-grown girl, +with an appearance and manner that made her look four years older. I +could find no signs of appendicitis, but I learned from her that she +had been for three months at a large girls' school, and that in a few +days' time her second term was due to begin. As we became friends, she +agreed that her appendicitis and her resolve not to return to school, +where she was unhappy, were but different ways of saying the same +thing. She was an only child who had travelled a great deal with her +parents, had found her interests in their pursuits, and had grown +backward in school work. The little girls with whom she was expected +to associate seemed to her mere children. The elder girls did not want +her friendship, and snubbed her. I prescribed a change to a small +boarding-school with only a few girls, where age differences would not +matter so much, and where she could make friends with girls older than +herself, though not more mature. + +Into their school life we need not follow the children. Happily the +time is past when schoolmasters and schoolmistresses were incapable of +understanding their charges, and confounded nervous exhaustion with +stupidity or timidity with incapacity. + +And so we come back to the point from which we started: + +The nervous infant, restless, wriggling, and constantly crying! The +nervous child, unstable, suggestible, passionate, and full of nameless +fears! The nervous schoolboy or schoolgirl prone to self-analysis, +subject-conscious, and easily exhausted! And how many and how various +are the manifestations of this temperament! Refusal of food, refusal +of sleep, negativism, irritability, and violent fits of temper, +vomiting, diarrhoea, morbid flushing and blushing, habit spasms, +phobias--all controlled not by reproof or by medicine, but by good +management and a clear understanding of their nature. + +The hygiene of the child's mind is as important as the hygiene of his +body, and both are studies proper for the doctor. Neuropathy and an +unsound, nervous organisation are often enough legacies from the +nervous disorders of childhood. + + + + +INDEX + + +Abdomen, prominent + +Abdominal symptoms of neurosis + +Accent, local, facility with which acquired + +Acetone, in breath and urine during cyclic vomiting + +Acidosis, accompanying cyclic vomiting + +Action, imitativeness of + liberty of, in early childhood + +Activities in the nursery + not to be restrained + without intervention of grown-up people + wonderful nature of + +Adenoid vegetations, night-terrors aggravated by + removal of, in treatment of enuresis + +Adolescence, and education on sexual matters + +Adults, child in relation to the society of + +Æsthetic sense, in early childhood + +Affection, in the child + +Air hunger, in cyclic vomiting + +Air swallowing, habitual action of + +Albuminuria, associated with faulty posture + cause of, in neuropaths + +Allimentary disturbances, symptom of + +Alkali, in treatment of cyclic vomiting + +Anæmia, of neuropaths + +Anorexia nervosa + A case illustrating + +Apnoea, fatal cases of + following burst of crying + twitching of facial muscles in + +Appetite, emotional states affecting + loss of, + case illustrating + causes and characteristics + treatment + means of stimulating + nature of the sensation of + +Apprehension, causes of + growth of neuroses in atmosphere of + +Artificial feeding + +Aspirin + +Asthma, treatment of + +Attention, child's love of attracting + examples of + +Authority, delight in defying + over-exercise of, by parents, results of + + +Babies. _See_ Newborn Baby + +Backward development + signs of + +"Bad form" + +Bad habits + +Bath, baby's first experience of + +Bed, dislike of + how overcome + efforts to resist preparation for + +Bedroom, airing and temperature of + +Bedtime + management at + +Bed wetting. _See_ Enuresis + +Behaviour. _See_ Conduct + +Bladder, hydrostatic distension of, for enuresis + +Boarding-schools, object of + +Bodily ailments, and instability of nervous control, connection between + _See also_ Disorders + +Body, + and mind, development of + development of + environment influencing + effect of mind on + gradual alterations in the shape of + infantile characteristics in later childhood + +Bone, and muscle, changes in, in infantile children + +Books, + child's attitude towards + educative value of + kinds most suitable + +Brachial nerve, pressure causing tetany + +Breast-feeding, + best time for + causes of failure in + observations on + _See also_ Lactation + +Breath-holding + action during + fatal cases of + phenomena of + +Bromides, administration of + to newborn baby + + +Cajoling, futility of + +Calcium bromide, in treatment of spasms + +Calcium metabolism, disturbance of + +Care, ill effects of excess of + +Carpo-pedal spasm + +Catarrhal infections + connection of rheumatism with, 155 + +Cerebral anæmia + +Cerebral circulation, stagnation of + +Cerebral exhaustion. _See_ Mental Exhaustion + +Cerebral functions, + rapid growth of + unstable in the child + _See also_ Mental + +Character, + formation of + during school life + home influence in the development of + ideals of, how inculcated + +Children's parties, disadvantages of + +Chloral, administration of + to newborn baby + in treatment of spasms + +Chorea, + and rheumatism, association between + symptom of cerebral irritability + treatment of + +Chvostek's sign, characteristics and nature of + +Circulation, cerebral, + stagnation of + nervous control of + +Claustrophobia + +Clothing, + kind suitable + new, child's delight in + +Coaxing, + futility of + +Cold douches, improving vasomotor tone + +Coldness of extremities + +Conduct, + control of, factors in + errors of, and sexual instincts + control of + correction of + due to faults of management + in neuropathic children + excessive introspection influencing + ideals of, how inculcated + influence of environment on + influenced by suggestion + mother's influence on + of neuropaths + perverse + suggestion in the control of + +Constipation, + mental causes of + negativism in + perversion of suggestion a common cause of + suggestion in relation to + +Constitution, delicacy of + +Convulsions, fatal cases of + generalised + +Convulsive disorders + +Cough, nervous + +Counter-opposition, child's opposition growing with + +Crying, constant + formation of habit of + in emotional and excitable children + management of + mechanism of + phenomena of + purposeful + +Cyclic or periodic vomiting. _See_ Vomiting + + +Day-dreams, indicating nervous temperament + +Deceit + +Defæcation, inhibition of + painful + +Delicacy of constitution + +Delirium, tendency to + +Depolarisation of ideas + +Depression, recurrence of periods of + +Dexterity, lack of + manual, advantages of + toys developing + +Diaphragm, spasm of + +Diarrhoea, mucous + +Diet, likes and dislikes for articles of + opposition to + of newborn child, changes in + _See also_ Food + +Digestion, emotional states affecting + +Digestive disorders, mental causes of + +Digestive neuroses + +Digestive system, symptoms of extreme sensibility of + +Dirt eating + +Discipline + in later childhood + in the school + misdirected efforts at enforcing + severe, effects of + +Dishonesty + +Disobedience, + growth of + habit of + personality and + perverse attitude of + reproof and coaxing causing + +Disorders, ætiology of + associated with neurosis + common + environment as cause and cure of + of neuropaths + treatment of + trifling + +Diuresis, excessive + +Doll, child's care of, an example of imitativeness + educative value of + +Douches, cold, improving vasomotor tone + +Dover's powder + +Dreams, + nature of, indicating nature of mental unrest + +Drugs, in sleeplessness + +Ductless glands, in relation to infantile characteristics + +Dullards + +Dyspepsia, complications of + course and effects of + mental aspects of + nervous symptoms of + symptoms in newborn infant + treatment + + +Early childhood, care during + impulse of opposition in + love of power in + +Early childhood, nervousness in + reasoning power in + three common neuroses of + toys, books, and amusements in + _See also_ Newborn Baby + +Education, aim of + by games and toys + on sexual matters + +Educative value, of books, games, and toys + +Emotional states, appetite affected by + causing spasm + management of + of neurotics, exaggeration of + physical disturbances due to + producing laryngismus stridulus + +Emotional storms + +Endocrine glands + +Enuresis, + causal factors in + characteristics and peculiarities of + condition of urine during + mental aspects of + mistakes in treatment of + perversion of suggestion as cause of + removal of tonsils in + treatment, essentials in + hypnotic suggestion in + methods of + +Environment, body moulded and shaped by + change of, beneficial effects of + effect in developing child's powers + effect on common disorders + errors of, and neuropathic children + essentials of + faulty contact with, in neuropathic children + for neuropaths + influence on conduct in later childhood + influence on mental processes + influence on personality + irritating nature of the adult mind in + of the home, reflected in the child + of school life + stimulus of + susceptibility to influences of + +Epilepsy, cyclical character of + +Evil, inborn disposition to + +Excitable children, management of + +Exercise, sleep in relation to + +Exhaustion. _See_ Mental Exhaustion + +Expostulation, frequent, bad effects of + _See also_ Reproof + +Expressions, to attract attention + + +Facial muscles, twitching of + associated with apnoea + +Fæces, incontinence of + +Fainting fits, + cause and characteristics + control of + of neuropaths + +Fatigue, mental, physical, and visceral + +Fats, lowered tolerance to + +Faults, correction of + not corrected by too frequent reproof + +Fear, + causes of + phenomena of + prominent psychical symptom of neuropathic children + treatment of + +Feeding, + artificial + factors in + of newborn infant, regularity in + +Fertilisation, method of imparting knowledge of + +Food, force of suggestion in relation to + healthy desire for + likes and dislikes for + how overcome + phenomena of the desire of + refusal of + nervous causes of + persistent, factors encouraging + suggestion in relation to + treatment of + +Force and cajoling, futility of + +Freud, teaching of + +Functional disturbances, in combination with organic disease + + +Gait, peculiarity of + +Games, educative value of + +Gastric disturbances + +Gastric juice, psychic secretion of + +Gastric symptoms, of neurosis + +Gastro-intestinal derangement, causes of + environment as cause and cure of + +Gentleness, + inculcation of + +Girls' schools + +Glottis, spasm of, strong emotion causing + +"Good form" + +Grasping habit, reproof in relation to + +Growing pains + + +Habit spasms, age of appearance of + cause of + definition of + examples of + spread of + suggestion in relation to + treatment of + +Habits, regulation of + suggestion in relation to + +Habitual actions, infant's pleasure in + mental unrest in relation to + of the parent, reproduction in the child + varieties and characteristics + +Habitual wakefulness + +Hands, control of movement of + expressionless + +Happiness and contentment, of child when playing alone + +Headache, periodic. _See_ Migraine + +Heat and cold, newborn baby in relation to + +Heat and flushing, sudden sensations of + +Heredity, and temperament + and type of child + nervous disorders in relation to + +Home influence, in development of character + reflected in the child + +Hunger, of the newborn baby + +Hypnotic suggestion, in treatment of enuresis + +Hypnotics + +Hysteria, + age of appearance of + suggestion in relation to + symptoms of + +Hysterical girls, characteristics of + + +Ideals, inculcation of + +Ideas, polarisation and depolarisation of + +Illness. _See_ Sickness + +Imagination, abnormal, correction of + child's stories and tales in relation to + developed by toys + +Imitativeness, age at which apparent + extent of + illustration of + lack of + of action + of speech + tell-tale child an illustration of + +Incontinence of urine + +Incorrigible children + +Infantile characteristics, + ductless glands in relation to + nervous system in relation to + +Infective disorders, + convalescence from + producing nervous symptoms + relation of neurosis to + +Inflammatory reactions + +Insomnia. _See_ Sleeplessness + +Intellect, compared with physique + +Intelligence, in early childhood + +Intestinal disturbance + of neurosis + symptom of + +Intoxications, violent reaction to + +Introspection, and neuropathic children + excessive, evidences of + influencing conduct + +Irritation, child to be free from + + +Joint pains + + +Kindergarten school, artificial symbolism of + +Kindness, inculcation of + + +Lactation, + care of child during + care of mother during + causes of failure in + establishment of + tongue-tie in relation to + +Laryngismus stridulus. _See_ Breath-holding + +Later childhood, + infantile characteristics in + management in + mental backwardness in + +Likes and dislikes + +Lordosis + and neurosis + producing albuminuria + + +Manual dexterity, advantages of + +Massage, improving tone of muscles + +Medicines, sensitiveness to + +Melancholy children + +Mental aspects, of digestive disorders + of enuresis + of management in early childhood + +Mental backwardness, + and infantile characteristics + in later childhood + +Mental disturbances, + cyclical character of + indicating neuropathic tendencies + irregularities of sleep due to + psycho-analysis of + +Mental exhaustion, + during convalescence from infective disorders + easily produced in nervous children + +Mental irritability, chorea a symptom of + +Mental life of the child + +Mental power, + active before beginning of speech + in early childhood + +Mental processes, development of + age at which most apparent + in later childhood + effect of unconscious suggestions on + heredity in relation to + influence of environment on + +Mental training + compared with physical training + objects and advantages of + +Mental unrest, + avoidance of + crying in relation to + digestive disturbances due to + growth of neuroses in atmosphere of + habitual actions in relation to + in the adult + in the child + negativism due to + of newborn infant, effects of + _See also_ Nervous Unrest + +Micturition, + functional disorder of + negativism in + regulation of + _See also_ Enuresis + +Migraine, + periodic vomiting associated with + symptom of nervous exhaustion + +Mind, + and body, development of + effect on the body + vigour of, in relation to that of body + +Money, theft of + +Montessori system of training + +Moral degeneracy + +Moral standard of school life + +Moral training + importance and effects of + negative virtues and + objects and advantages of + parents' responsibilities in + +Morals, public opinion forming code of + +Morbid introspection + +Mothers, + ability and inability to manage children + attitude in regard to temperament of child + care of, during lactation + conduct of child influenced by + inability to understand nature of child's disorders + influence of, on tone and manner of speech + mental environment of child created by + personality of + relation to the child + +Motionless children + +Mouth, habit of conveying everything to, cause of + +Movements, + precision of + purposive, development of + self-command of + +Muscular atrophy, and neurosis + +Muscular system, + changes in infantile children + weak development of + +Muscular tone, how improved + +Myopathy, primary + + +Nasal obstruction + and failure of lactation + night-terrors aggravated by + +Natural history, sexual matters taught by + +Naughtiness, child's delight in + +Naughty, use of the term + +Negative virtues, and moral training + +Negativism, + cause of + characteristics + factors developing + in constipation + in micturition + spirit of + treatment of + want of sleep depending on + +Nerve centres, controlling movement, development of + +Nervous control, instability of, connection between bodily ailments and + +Nervous cough + +Nervous disorders, + and psycho-analysis + common, causes, characteristics, and treatment + frequency of + +Nervous exhaustion, cyclic vomiting and migraine symptoms of + +Nervous instability, stigma of + +Nervous system, abnormal in children + in relation to cyclic vomiting + increased irritability of + infantile characteristics of + +Nervous unrest, environment in relation to + factors increasing + manifestations of + recurrence of periods of + symptoms of + _See also_ Mental Unrest + +Nervous vomiting. _See_ Vomiting + +Nervousness, and digestive disorders + and neuropathy + in early infancy + in older children + parents' attitude causing + +Nettlerash + +Neurasthenia + +Neuropathic children, common symptoms of + conduct of + faulty contact with environment in + fear the prominent symptom of + introspection and self-consciousness of + management of + training of + +Neuropathic tendencies, evidence of, in older children + +Neuropaths, adult + faulty management in child life leading to + phenomena of + phobias of + selection of suitable environment for + symptoms of + +Neuroses, and psycho-analysis + association of albuminuria with + constipation frequently due to + examination of + growth in atmosphere of unrest and apprehension + relation of, to infection of the body + treatment of + +Neurotics, and physique + characteristics + exaggeration of emotions of + +Newborn baby, administration of sedatives to + artificial feeding of + breast feeding of + case of + effect of mental unrest on + first impressions of + formation of habits of sleep and crying in + heat and cold in relation to + hunger of + induction of the sucking movements of + of nervous inheritance + personality of + prevention of restlessness and crying + reduction of sense stimuli in + reflex action of sucking in + sense of taste of + symptoms of dyspepsia in + times of feeding + weaning of + +Night-terrors, aggravation of, + causes of + of neuropathic children + +Nursery, activities in, child's interest in + importance of child's being alone in + observations in + +Nursery life, advantages of + +Nursery psycho-therapeutics + +Nurses, ability and inability to manage children + influence of, on tone and manner of speech + mental environment of child created by + personality of + +Nursing, during sickness + of the newborn infant + + +Obedience + and perverse pleasure + growth of + +Obsession of bed wetting + +Opposition + and counter-opposition + during sickness + force of, factors influencing development + habit of + impulse of + love of, in early childhood + to food + +Organic disturbance, in combination with functional trouble + + +Pain, frequent loss of sense of, in neuropaths + +Pallor + sudden attacks of + +Palpitation, example of visceral fatigue + +Parathyroid glands, function of + +Parents, + and children, conflict between + and silence on sexual matters + habitual actions of, reproduced in the child + mental attitude of, in relation to conduct + over-exercise of authority by, results of + responsibilities in moral training of child + suggestions unconsciously conveyed by, evil results of + +Parties, disadvantages of + +Patient, temperament of, physician in relation to + +Pelvis, development of + +Peripheral nerves, increase in irritability and conductivity of + +Personal adornment, delight in + +Personality, + and disobedience + child's own conception of + environment influencing + in early childhood + of newborn baby + +Perspiration, abundant, sudden attacks of, 141 + +Phobias, + characteristics and varieties + frequency of + treatment of + +Physical defects, accompanying neurosis + +Physical disturbances, due to emotion + +Physical exercise, lack of, causing want of sleep + +Physical fatigue, easily produced in nervous children + +Physical phenomena of neuropaths + +Physical training, + objects and advantages of + +Physician, + and the temperament of his patient + examination by + diagnosis by + difficulties of + +Physique, intellect compared with + +Pica and dirt eating + +Picture books, + educative value of + kinds most suitable + +Play, + happiness of child during + in the nursery + with grown-up persons + +Pleasure, sense of, in early childhood + +Polarisation of ideas + +Postural albuminuria + +Posture, faulty + prevention of + +Power, child's love of + +Precision of movement, development of + +Psycho-analysis, + dangers of + observations on + +Public schools, character and effects of + +Punishment, + deserved and undeserved + frequent, disadvantages of + observations on + +Purity, inculcation of high ideals of, + +Purposive movements, earliest, + cause of + encouragement of + +Pyloric spasm + +Pyrexia, + organic disease in relation to + + +Rational hygiene + +Reasoning power, + active before advent of speech + factors influencing development of + +Regulation of habits + +Repression, by older children of younger + +Reproduction, method of imparting knowledge of + +Reproof, + cases in which useless + causing disobedience + effects of + extreme sensitiveness to + perverse pleasure of + too frequent repetition of, futility of + +Restlessness, during sickness + +Rewards, use and dangers of + +Rheumatism, + and chorea, association between + characteristics in childhood + subacute + treatment of + +Rickets, + mental and intellectual condition in + in infantile children + occurrence with spasmophilia + +Right and wrong, appreciation of, in early childhood + +Round shoulders + + +St. Vitus's dance + +Salts, excretion of + +School life, + and sexual matters + moral standard of + moral training and + moulding of character during + of boys + of girls + +Schools, public, character and effects of + +Scoliosis, prevention of + +Secretions, anomalies of + +Self, child's conception of + +Self-conscious children, complaints of + +Self-consciousness, of neuropathic children + +Self-discipline, development of + +Self-education, in the nursery + +Self-feeding + +Self-preservation, morbid instinct of + +Self-sacrifice, not to be expected in early childhood + +Sensations, + acuteness of + bodily, of neuropaths + +Sense perception, of neuropaths + +Sense stimuli, + cultivation of perception of + in newborn babies + +Sexual matters, + education on + method of + errors of conduct and + parents' silence in regard to + psycho-analysis in relation to + school life in relation to + +Sickness + evil effects of suggestions unconsciously conveyed by parents during + management during + nurse and mother during + opposition during + temperature during + therapeutic measures in + therapeutic procedures concentrating child's mind on his symptoms + +Sleep, estimation of the amount of + force of suggestion in relation to + formation of habit of + light and broken, cause of + of newborn infant + sound, beneficial effects of + +Sleeping attire + +Sleeplessness, breaking of the habit of + causes and characteristics + drugs in + in older children + lack of physical exercise causing + suggestion in relation to + treatment of + +Sleep-walking + +Snatching, habit of + +Spasmophilia + ætiology of + drugs in treatment of + occurrence of rickets with + +Spasms, control of + fatal + +Speech, beginnings of + facility with which local accent is acquired + imitativeness of + infant's reasoning power present before advent of + influence of nurses and mothers on tone and manner of + +Spinal deformity, prevention of + +Spinal muscles, atrophy of + +Spoon feeding + +Status catarrhalis + +Status lymphaticus + +Story-telling + +Sucking movements, of newborn child, induction of + _see also_ Lactation + +Suggestion, and habit spasms + appetite in relation to + bed wetting in relation to + bodily habits in relation to + characteristics + conduct influenced by + constipation in relation to + effect on mental processes + food in relation to + force of, on child's mind + hysteria in relation to + perverse influence of + bad habits due to + causing constipation + want of sleep depending upon + refusal of food in relation to + sleep in relation to + susceptibility to + unconsciously conveyed by parents, evil results of + +Suicide + +Suspicions, aroused in the child + +Syncopal attacks, causes and characteristics + + +Tactile sensation. _See_ Touch + +Taste, perversion of + sensations of + how controlled + sense of, in newborn infant + +Teething convulsions + +Tell-tale child, characteristics + +Temperament, diversity of + heredity and + mother's attitude in relation to + of the patient, physician in relation to + +Temperature, during sickness + inexplicable rises in + +Terror, causes, of + +Tetany, liability to, in increased irritability of nervous system + pressure to brachial nerve causing + +Theatres, disadvantages of + +Theft + +Therapeutic conversation + +Thigh rubbing, + avoidance of + characteristics + habitual action of + +Thorax, development of + +Thumb sucking + persistence of the habit + +Tongue-tie, in relation to lactation + +Tonics + +Tonsils, removal of, in treatment of enuresis + +Touch, sense of, + cultivation of + early development of + organs with greatest development of + +Toys, + child's interest in + educative value of + kind most suitable + +Training, early, importance and object of + +Trousseau's sign, nature and production of + +Truthfulness + inculcation of + +Twitching of facial muscles + +Tyranny of tears + + +Unkindness, habitual, of children to others + +Untruthfulness + over-exercise of authority encouraging + +Urine, + condition in enuresis + incontinence of, methods of treatment + _See also_ Enuresis + increased secretion of + irritation of + + +Vasomotor instability + conditions indicating + in neuropaths + +Vasomotor tone, how improved + +Virtuous, definition of the term + +Visceral fatigue, easily produced in nervous children + +Vocabulary + +Voice, tone of + +Voluntary movements, development of cerebral centres controlling + +Vomiting, cyclic + ætiology of + age at which it occurs + case illustrating + causes and characteristics + class of child affected by + condition of the child during + frequency of attacks + migraine in association with + nervous system in relation to + treatment of + + +Waking states + +Weaning, difficulty in + +Will, strength of, absence in childhood + +Work and play, differentiation between + +Writing, correct posture during + + + + +Transcriber's Notes + +The following typographical errors were corrected: +Page 4: 'sensisive' changed to 'sensitive'. +Page 48: 'self-abnegnatio'n changed to 'self-abnegation'. +page 61: Fixed 'and and'. +Page 125: 'acount' changed to 'account'. +First page of index (191): 'ullimentary' changed to 'Allimentary'; + also 'ilstrating' channged to 'illustrating'. + + + + + +End of Project Gutenberg's The Nervous Child, by Hector Charles Cameron + +*** END OF THE PROJECT GUTENBERG EBOOK 14515 *** diff --git a/14515-h/14515-h.htm b/14515-h/14515-h.htm new file mode 100644 index 0000000..e37fdd1 --- /dev/null +++ b/14515-h/14515-h.htm @@ -0,0 +1,6502 @@ +<?xml version="1.0" encoding="UTF-8"?> +<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN" + "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd"> + +<html xmlns="http://www.w3.org/1999/xhtml"> + <head> + <title> + The Project Gutenberg eBook of The Nervous Child, by Hector Charles Cameron. + </title> + <style type="text/css"> +/*<![CDATA[ XML blockout */ +<!-- + p { margin-top: .75em; + text-align: justify; + margin-bottom: .75em; + line-height: 120%; + } + h1,h2,h3,h4,h5,h6 { + text-align: center; /* all headings centered */ + clear: both; + } + hr { width: 33%; + margin-top: 2em; + margin-bottom: 2em; + margin-left: auto; + margin-right: auto; + clear: both; + } + + table {margin-left: auto; margin-right: auto;} + + body{margin-left: 10%; + margin-right: 10%; + } + + .linenum {position: absolute; top: auto; left: 4%;} /* poetry number */ + .blockquot{margin-left: 5%; margin-right: 10%;} + .pagenum {position: absolute; left: 92%; font-size: smaller; text-align: right;} /* page numbers */ + .sidenote {width: 20%; padding-bottom: .5em; padding-top: .5em; + padding-left: .5em; padding-right: .5em; margin-left: 1em; + float: right; clear: right; margin-top: 1em; + font-size: smaller; background: #eeeeee; border: dashed 1px;} + + .bb {border-bottom: solid 2px;} + .bl {border-left: solid 2px;} + .bt {border-top: solid 2px;} + .br {border-right: solid 2px;} + .bbox {border: solid 2px;} + + .center {text-align: center;} + .smcap {font-variant: small-caps;} + + .subhead {margin-top: 1.5em; + margin-bottom: 1.0em; + text-align: center; + font-size: larger; + font-variant: small-caps;} + + .in1 {margin-left: 1em;} + .in2 {margin-left: 2em;} + + .figcenter {margin: auto; text-align: center;} + + .figleft {float: left; clear: left; margin-left: 0; margin-bottom: 1em; margin-top: + 1em; margin-right: 1em; padding: 0; text-align: center;} + + .figright {float: right; clear: right; margin-left: 1em; margin-bottom: 1em; + margin-top: 1em; margin-right: 0; padding: 0; text-align: center;} + + .footnotes {border: dashed 1px;} + .footnote {margin-left: 10%; margin-right: 10%; font-size: 0.9em;} + .footnote .label {position: absolute; right: 84%; text-align: right;} + .fnanchor {vertical-align: super; font-size: .8em; text-decoration: none;} + + .poem {margin-left:10%; margin-right:10%; text-align: left;} + .poem br {display: none;} + .poem .stanza {margin: 1em 0em 1em 0em;} + .poem span {display: block; margin: 0; padding-left: 3em; text-indent: -3em;} + .poem span.i2 {display: block; margin-left: 2em;} + .poem span.i4 {display: block; margin-left: 4em;} + // --> + /* XML end ]]>*/ + </style> + </head> +<body> +<div>*** START OF THE PROJECT GUTENBERG EBOOK 14515 ***</div> + +<h1>THE NERVOUS CHILD</h1> + +<p> </p> +<p> </p> + +<h4>PUBLISHED BY THE JOINT COMMITTEE OF</h4> +<h4>HENRY FROWDE, HODDER & STOUGHTON</h4> +<h4>17 WARWICK SQUARE, LONDON, E.C. 4</h4> + +<p> </p> +<p> </p> + +<h1>THE</h1> +<h1>NERVOUS CHILD</h1> + +<p> </p> + +<h3>BY</h3> + +<h2>HECTOR CHARLES CAMERON</h2> +<h4>M.A., M.D.(<span class="smcap">Cantab.</span>), F.R.C.P.(<span class="smcap">Lond.</span>)</h4> +<h4>PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF</h4> +<h4>THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL</h4> + +<p> </p> +<p> </p> + +<div class="blockquot"><p>"RESPECT the child. Be not too much his parent. Trespass not on + his solitude."—<span class="smcap">Emerson.</span></p></div> + +<p> </p> +<p> </p> + +<h3>LONDON</h3> +<h3>HENRY FROWDE HODDER & STOUGHTON</h3> +<h3><span class="smcap">Oxford University Press Warwick Square, E.C.</span></h3> +<h4>1920</h4> + +<p> </p> +<p> </p> + +<h4><i>First Edition</i> 1919</h4> +<h4><i>Second Impression</i> 1930</h4> + +<p> </p> +<p> </p> + +<h4><span class="smcap">Printed in Great Britain</span></h4> +<h4><span class="smcap">By Morrison & Gibb Ltd., Edinburgh</span></h4> + +<p> </p> +<p> </p> + +<hr style="width: 65%;" /> +<h2><a name="PREFACE" id="PREFACE" />PREFACE</h2> + +<p> </p> +<p>To-day on all sides we hear of the extreme importance of Preventive +Medicine and the great future which lies before us in this aspect of +our work. If so, it follows that the study of infancy and childhood +must rise into corresponding prominence. More and more a considerable +part of the Profession must busy itself in nurseries and in schools, +seeking to apply there the teachings of Psychology, Physiology, +Heredity, and Hygiene. To work of this kind, in some of its aspects, +this book may serve as an introduction. It deals with the influences +which mould the mentality of the child and shape his conduct. Extreme +susceptibility to these influences is the mark of the nervous child.</p> + +<p>I have to thank the Editors of <i>The Practitioner</i> and of <i>The Child</i>, +respectively, for permission to reprint the chapters which deal with +"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I +should also like to offer thanks for helpful suggestions.</p> + +<p>H.C.C.</p> + +<p><i>March</i> 1919.</p> +<p> </p> +<p> </p> + +<h3>CONTENTS</h3> + + + +<table cellspacing="0" cellpadding="4" border="0" summary="Table of Contents"> +<tr> + <th align="left">CHAP.</th> + <th> </th> + <th align="center">PAGE</th> +</tr> +<tr> + <td align="right">I.</td> + <td align="left"><span class="smcap"><a href="#Page_1">Doctors, Mothers, and Children</a></span></td> + <td align="right">1</td> +</tr> +<tr> + <td align="right">II.</td> + <td align="left"><span class="smcap"><a href="#Page_18">Observations in the Nursery</a></span></td> + <td align="right">18</td> +</tr> +<tr> + <td align="right">III.</td> + <td align="left"><span class="smcap"><a href="#Page_50">Want of Appetite and Indigestion</a></span></td> + <td align="right">50</td> +</tr> +<tr> + <td align="right">IV.</td> + <td align="left"><span class="smcap"><a href="#Page_64">Want of Sleep</a></span></td> + <td align="right">64</td> +</tr> +<tr> + <td align="right">V.</td> + <td align="left"><span class="smcap"><a href="#Page_73">Some Other Signs of Nervousness</a></span></td> + <td align="right">73</td> +</tr> +<tr> + <td align="right">VI.</td> + <td align="left"><span class="smcap"><a href="#Page_89">Enuresis</a></span></td> + <td align="right">89</td> +</tr> +<tr> + <td align="right">VII.</td> + <td align="left"><span class="smcap"><a href="#Page_96">Toys, Books, and Amusements</a></span></td> + <td align="right">96</td> +</tr> +<tr> + <td align="right">VIII.</td> + <td align="left"><span class="smcap"><a href="#Page_104">Nervousness in Early Infancy</a></span></td> + <td align="right">104</td> +</tr> +<tr> + <td align="right">IX.</td> + <td align="left"><span class="smcap"><a href="#Page_117">Management in Later Childhood</a></span></td> + <td align="right">117</td> +</tr> +<tr> + <td align="right">X.</td> + <td align="left"><span class="smcap"><a href="#Page_131">Nervousness in Older Children</a></span></td> + <td align="right">131</td> +</tr> +<tr> + <td align="right">XI.</td> + <td align="left"><span class="smcap"><a href="#Page_145">Nervousness and Physique</a></span></td> + <td align="right">145</td> +</tr> +<tr> + <td align="right">XII.</td> + <td align="left"><span class="smcap"><a href="#Page_160">The Nervous Child in Sickness</a></span></td> + <td align="right">160</td> +</tr> +<tr> + <td align="right">XIII.</td> + <td align="left"><span class="smcap"><a href="#Page_169">Nervous Children and Education on Sexual Matters</a></span></td> + <td align="right">169</td> +</tr> +<tr> + <td align="right">XIV.</td> + <td align="left"><span class="smcap"><a href="#Page_182">The Nervous Child and School</a></span></td> + <td align="right">182</td> +</tr> +<tr> + <td align="right"> </td> + <td align="left"><span class="smcap"><a href="#Page_191">Index</a></span></td> + <td align="right">191</td> +</tr> +</table> + + +<p> </p> +<hr style="width: 65%;" /> +<p> </p> + +<h2>THE NERVOUS CHILD</h2> + +<p><span class="pagenum">Page 1<a name="Page_1" id="Page_1"></a></span></p> + +<h3>CHAPTER I</h3> + +<h3>DOCTORS, MOTHERS, AND CHILDREN</h3> + + +<p>There is an old fairy story concerning a pea which a princess once +slept upon—a little offending pea, a minute disturbance, a trifling +departure from the normal which grew to the proportions of intolerable +suffering because of the too sensitive and undisciplined nervous +system of Her Royal Highness. The story, I think, does not tell us +much else concerning the princess. It does not tell us, for instance, +if she was an only child, the sole preoccupation of her parents and +nurses, surrounded by the most anxious care, reared with some +difficulty because of her extraordinary "delicacy," suffering from a +variety of illnesses which somehow always seemed to puzzle the +doctors, though some of the symptoms—the vomiting, for example, and +the high temperature—were very severe and persistent. Nor does it +tell us if later in life, but before the suffering from the pea arose, +she had been taken to consult two famous doctors, one of whom had +removed the vermiform appendix, while the other a little later had +performed an operation for "adhesions." +<span class="pagenum">Page 2<a name="Page_2" id="Page_2"></a></span> +At any rate, the story with +these later additions, which are at least in keeping with what we know +of her history, would serve to indicate the importance which attaches +to the early training of childhood. Among the children even of the +well-to-do often enough the hygiene of the mind is overlooked, and +faulty management produces restlessness, instability, and +hyper-sensitiveness, which pass insensibly into neuropathy in adult +life.</p> + +<p>To prevent so distressing a result is our aim in the training of +children. No doubt the matter concerns in the first place parents and +nurses, school masters and mistresses, as well as medical men. Yet +because of the certainty that physical disturbances of one sort or +another will follow upon nervous unrest, it will seldom happen that +medical advice will not be sought sooner or later; and if the +physician is to intervene with success, he must be prepared with +knowledge of many sorts. He must be prepared to make a thorough and +complete physical examination, sufficient to exclude the presence of +organic disease. If no organic disease is found, he must explore the +whole environment of the child, and seek to determine whether the +exciting cause is to be found in the reaction of the child to some +form of faulty management.</p> + +<p>For example, a child of two or three years of age may be brought to +the doctor with the complaint that defæcation is painful, and that +there has existed for some time a most distressing constipation which +has resisted a large number of purgatives of increasing strength. +Whenever the child is placed upon the +<span class="pagenum">Page 3<a name="Page_3" id="Page_3"></a></span> +stool, his crying at once +begins, and no attempts to soothe or console him have been successful. +It is not sufficient for the doctor in such a case to make an +examination which convinces him that there is no fissure at the anus +and no fistula or thrombosed pile, and to confine himself to saying +that he can find nothing the matter. The crying and refusal to go to +stool will continue after the visit as before, and the mother will be +apt to conclude that her doctor, though she has the greatest +confidence in him for the ailments of grown-up persons, is unskilled +in, or at least not interested in, the diseases of little children. +If, on the other hand, the doctor pursues his inquiries into the +management of the child in the home, and if, for example, he finds +that the crying and resistance is not confined to going to stool, but +also takes place when the child is put to bed, and very often at +meal-times as well, then it will be safe for him to conclude that all +the symptoms are due to the same cause—a sort of "negativism" which +is apt to appear in all children who are directed and urged too much, +and whose parents are not careful to hide from them the anxiety and +distress which their conduct occasions.</p> + +<p>If this diagnosis is made, then a full and clear explanation should be +given to the mother, or at any rate to such mothers—and fortunately +they are in the majority—who are capable of appreciating the point of +psychology involved, and of correcting the management of the child so +as to overcome the negativism. To attempt treatment by prescribing +drugs, or in any other way than by correcting the +<span class="pagenum">Page 4<a name="Page_4" id="Page_4"></a></span> +faulty management, +is to court failure. As Charcot has said, in functional disorders it +is not so much the prescription which matters as the prescriber.</p> + +<p>But the task of the doctor is often one of even greater difficulty. +Often enough there will be a combination of organic disturbance with +functional trouble. For example, a girl of eighteen years old suffered +from a pain in the left arm which has persisted on and off since the +olecranon had been fractured when she was two years of age. She was +the youngest of a large family, and had never been separated for a day +from the care and apprehensions of her mother. The joint was stiff, +and there was considerable deformity. The pain always increased when +she was tired or unhappy. Again, a girl had some slight cystitis with +frequent micturition, and this passed by slow degrees into a purely +functional irritability of the bladder, which called for micturition +at frequent intervals both by day and night. In such cases treatment +must endeavour to control both factors—the local organic disturbance +must if possible be removed, and the faults of management corrected.</p> + +<p>It is a good physician who can appreciate and estimate accurately the +temperament of his patient, and the need for this insight is nowhere +greater than in dealing with the disorders of childhood. It can be +acquired only by long practice and familiarity with children. In the +hospital wards we shall learn much that is essential, but we shall not +learn this. The child, who is so sensitive to his environment, shows +but little that is +<span class="pagenum">Page 5<a name="Page_5" id="Page_5"></a></span> +characteristic when admitted to an institution. +Only in the nursery can we learn to estimate the influences which +proceed from parents and nurses of different characters and +temperaments, and the reaction which is produced by them in the child.</p> + +<p>The body of the child is moulded and shaped by the environment in +which it grows. Pure air, a rational diet, free movement, give +strength and symmetry to every part. Faults of hygiene debase the +type, although the type is determined by heredity which in the +individual is beyond our control. Mothers and nurses to-day are well +aware of the need for a rational hygiene. Mother-craft is studied +zealously and with success, and there is no lack of books to give +sound guidance and to show the mean between the dangerous extremes of +coddling and a too Spartan exposure. Yet sometimes it has seemed as if +some mothers whose care for their children's physical health is most +painstaking, who have nothing to learn on the question of diet, of +exercise, of fresh air, or of baths, who measure and weigh and record +with great minuteness, have had their attention so wholly occupied +with the care of the body that they do not appreciate the simultaneous +growth of the mind, or inquire after its welfare. Yet it is the +astounding rapidity with which the mental processes develop that forms +the distinguishing characteristic of the infancy of man. Were it not +for this rapid growth of the cerebral functions, the rearing of +children would be a matter almost as simple and uneventful as the +rearing of live stock. For most +<span class="pagenum">Page 6<a name="Page_6" id="Page_6"></a></span> +animals faults of environment must be +very pronounced to do harm by producing mental unrest and +irritability. Thus, indeed, some wild animal separated from its +fellows and kept in solitary captivity may sicken and waste, though +maintained and fed with every care. Yet if the whole conditions of +life for the animal are not profoundly altered, if the environment is +natural or approximately natural, it is as a rule necessary to care +only for its physical needs, and we need not fear that the results +will be spoiled by the reaction of the mind upon the body. But with +the child it is different; airy nurseries, big gardens, visits to the +seaside, and every advantage that money can buy cannot achieve success +if the child's mind is not at rest, if his sleep is broken, if food is +habitually refused or vomited, or if to leave him alone in the nursery +for a moment is to evoke a fit of passionate crying.</p> + +<p>The grown-up person comes eventually to be able to control this +tremendous organ, this brain, which is the predominant feature of his +race. In the child its functions are always unstable and liable to be +upset. Evidence of mental unrest or fatigue, which is only rarely met +with in grown persons and which then betokens serious disturbance of +the mind, is of comparatively common occurrence in little children. +Habit spasm, bed-wetting, sleep-walking, night terrors, and +convulsions are symptoms which are frequent enough in children, and +there is no need to be unduly alarmed at their occurrence. In adult +age they are found only +<span class="pagenum">Page 7<a name="Page_7" id="Page_7"></a></span> +among persons who must be considered as +neuropathic. To make the point clear, I have chosen examples from the +graver and more serious symptoms of nervous unrest. But it is equally +true that minor symptoms which in adults are universally recognised to +be dependent upon cerebral unrest or fatigue are of everyday +occurrence in childhood. Broken and disturbed sleep, absence of +appetite and persistent refusal of food, gastric pain and discomfort +after meals, nervous vomiting, morbid flushing and blushing, headache, +irritability and excessive emotional display, at whatever age they +occur, are indications of a mind that is not at rest. In children, as +in adults, they may be prominent although the physical surroundings of +the patient may be all that could be desired and all that wealth can +procure. It is an everyday experience that business worries and +responsibilities in men, domestic anxieties or childlessness in women, +have the power to ruin health, even in those who habitually or grossly +break none of its laws. The unstable mind of the child is so sensitive +that cerebral fatigue and irritability are produced by causes which +seem to us extraordinarily trivial. In the little life which the child +leads, a life in which the whole seems to us to be comprised in +dressing and undressing, washing, walking, eating, sleeping, and +playing, it is not easy to detect where the elements of nervous +overstrain lie. Nor is it as a rule in these things that the mischief +is to be found. It is in the personality of mother or nurse, in her +conduct to the child, in her actions and words, in the tone of +<span class="pagenum">Page 8<a name="Page_8" id="Page_8"></a></span> +her voice when she addresses him, even in the thoughts which pass through +her mind and which show themselves plainly to that marvellously acute +intuition of his, which divines what she has not spoken, that we must +seek for the disturbing element. The mental environment of the child +is created by the mother or the nurse. That is her responsibility and +her opportunity. The conduct of the child must be the criterion of her +success. If things go wrong, if there is constant crying or +ungovernable temper, if sleep and food are persistently refused, or if +there is undue timidity and tearfulness, there is danger that seeds +may be sown from which nervous disorders will spring in the future.</p> + +<p>There are many women who, without any deep thought on the matter, have +the inborn knack of managing children, who seem to understand them, +and have a feeling for them. With them, we say, the children are +always good, and they are good because the element of nervous +overstrain has not arisen. There are other women, often very fond of +children, who are conspicuously lacking in this power. Contact with +one of these well-meaning persons, even for a few days, will +demoralise a whole nursery. Tempers grow wild and unruly, sleep +disappears, fretfulness and irritability take its place. Yet of most +mothers it is probably true that they are neither strikingly +proficient nor utterly deficient in the power of managing children. If +they lack the gift that comes naturally to some women, they learn from +experience and grow instinctively to feel when they have made a false +step with the +<span class="pagenum">Page 9<a name="Page_9" id="Page_9"></a></span> +child. Although by dearly bought experience they learn +wisdom in the management of their children, they nevertheless may not +study the subject with the same care which they devote to matters of +diet and hygiene. It is the mother whose education and understanding +best fits her for this task. In this country a separate nursery and a +separate nursery life for the children is found in nearly all +households among the well-to-do, and the care for the physical needs +of the children is largely taken off the mothers' shoulders by nurses +and nursemaids. That this arrangement is advantageous on the whole +cannot be doubted. In America and on the Continent, where the children +often mingle all day in the general life of the household, and occupy +the ordinary living rooms, experience shows that nerve strain and its +attendant evils are more common than with us. Nevertheless, the +arrangement of a separate nursery has its disadvantages. Nurses are +sometimes not sufficiently educated to have much appreciation of the +mental processes of the child. If the children are restless and +nervous they are content to attribute this to naughtiness or to +constipation, or to some other physical ailment. Their time is usually +so fully occupied that they cannot be expected to be very zealous in +reading books on the management of children. Nevertheless, in +practical matters of detail a good nurse will learn rapidly from a +mother who has given some attention to the subject, and who is able to +give explicit instructions upon definite points.</p> + +<p><span class="pagenum">Page 10<a name="Page_10" id="Page_10"></a></span> +It is right that mothers should appreciate the important part which +the environment plays in all the mental processes of children, and in +their physical condition as well; that they should understand that +good temper and happiness mean a proper environment, and that constant +crying and fretfulness, broken sleep, refusal of food, vomiting, undue +thinness, and extreme timidity often indicate that something in this +direction is at fault.</p> + +<p>Nevertheless, we must be careful not to overstate our case. We must +remember how great is the diversity of temperament in children—a +diversity which is produced purely by hereditary factors. The task of +all mothers is by no means of equal difficulty. There are children in +whom quite gross faults in training produce but little permanent +damage; there are others of so sensitive a nervous organisation that +their environment requires the most delicate adjustment, and when +matters have gone wrong, it may be very difficult to restore health of +mind and body. When a peculiarly nervous temperament is inherited, +wisdom in the management of the child is essential, and may sometimes +achieve the happiest results. Heredity is so powerful a factor in the +development of the nervous organisation of the child that, realising +its importance, we should be sparing in our criticism of the results +which the mothers who consult us achieve in the training of their +children. A sensitive, nervous organisation is often the mark of +intellectual possibilities above the average, and the children who are +cast outside the ordinary mould, who are +<span class="pagenum">Page 11<a name="Page_11" id="Page_11"></a></span> +the most wayward, the most +intractable, who react to trifling faults of management with the most +striking symptoms of disturbance, are often those with the greatest +potentialities for achievement and for good. It is natural for the +mother of placid, contented, and perhaps rather unenterprising +children, looking on as a detached outsider, seeing nothing of the +teeming activities of the quick, restless little brain, and the +persistent, though faulty reasoning—it is natural for her to blame +another's work, and to flatter herself that her own routine would have +avoided all these troublesome complications. The mother of the nervous +child may often rightly take comfort in the thought that her child is +worth the extra trouble and the extra care which he demands, because +he is sent into the world with mechanism which, just because it is +more powerful than the common run, is more difficult to master and +takes longer to control and to apply for useful ends.</p> + +<p>It is through the mother, and by means of her alone, that the doctor +can influence the conduct of the child. Without her co-operation, or +if she fails to appreciate the whole situation, with the best will in +the world, we are powerless to help. Fortunately with the majority of +educated mothers there is no difficulty. Their powers of observation +in all matters concerning their children are usually very great. It is +their interpretation of what they have observed that is often faulty. +Thus, in the example given above, the mother observes correctly that +defæcation is inhibited, and produces crying +<span class="pagenum">Page 12<a name="Page_12" id="Page_12"></a></span> +and resistance. It is +her interpretation that the cause is to be found in pain that is at +fault. Again, a mother may bring her infant for tongue-tie. She has +observed correctly that the child is unable to sustain the suction +necessary for efficient lactation, and has hit upon this fanciful and +traditional explanation. The doctor, who knows that the tongue takes +no part in the act of sucking, will probably be able to demonstrate +that the failure to suck is due to nasal obstruction, and that the +child is forced to let go the nipple because respiration is impeded. +The opportunities for close observation of the child which mothers +enjoy are so great that we shall not often be justified in +disregarding their statements. But if we are able to give the true +explanation of the symptoms, it will seldom happen that the mother +will fail to be convinced, because the explanation, if true, will fit +accurately with all that has been observed. Thus the mother of the +child in whom defæcation is inhibited by negativism may have made +further observations. For example, she may have noted that the +so-called constipation causes fretfulness, that it is almost always +benefited by a visit to the country or seaside, or that it has become +much worse since a new nurse, who is much distressed by it, has taken +over the management of the child. To this mother the explanation must +be extended to fit these observations, of the accuracy of which there +need be no doubt. Fretfulness and negativism with all children whose +management is at fault come in waves and cycles. The child, naughty +and almost unmanageable one +<span class="pagenum">Page 13<a name="Page_13" id="Page_13"></a></span> +week, may behave as a model of propriety +the next. The negativism and refusal to go to stool are the outcome of +the nervous unrest, not its cause. Again, the nervous child, like the +adult neuropath, very often improves for the time being with every +change of scene and surroundings. It is the <i>ennui</i> and monotony of +daily existence, in contact with the same restricted circle, that +becomes insupportable and brings into prominence the lack of moral +discipline, the fretfulness, and spirit of opposition. Lastly, the +conduct of the nervous child is determined to a great extent by +suggestions derived from the grown-up people around him. Refusal of +food, refusal of sleep, refusal to go to stool, as we shall see later, +only become frequent or habitual when the child's conduct visibly +distresses the nurse or mother, and when the child fully appreciates +the stir which he is creating. The mother will readily understand that +in such a case, where constipation varies in degree according as +different persons take charge of the child, the explanation offered is +that which alone fits with the observed facts. A full and free +discussion between mother and doctor, repeated it may be more than +once, may be necessary before the truth is arrived at, and a line of +action decided upon. Only so can the doctor, remote as he is from the +environment of the child, intervene to mould its nature and shape its +conduct.</p> + +<p>If the doctor is to fit himself to give advice of this sort, he must +be a close observer of little children. He must not consider it +beneath his dignity to study +<span class="pagenum">Page 14<a name="Page_14" id="Page_14"></a></span> +nursery life and nursery ways. There he +will find the very beginnings of things, the growing point, as it +were, of all neuropathy. A man of fifty, who in many other ways showed +evidence of a highly nervous temperament, had especially one +well-marked phobia, the fear of falling downstairs. It had never been +absent all his life, and he had grown used to making the descent of +the stairs clinging firmly to the stair-rail. Family tradition +assigned this infirmity to a fall downstairs in early childhood. But +all children fall downstairs and are none the worse. The persistence +of the fear was due, I make no doubt, to the attitude of the parents +or nurse, who made much of the accident, impressed the occasion +strongly on the child's memory, and surrounded him thereafter with +precautions which sapped his confidence and fanned his fears.</p> + +<p>In what follows we will consider first the subject of nursery +management, searching in it for the origin of the common disorders of +conduct both of childhood and of later life. I have grouped these +nursery observations under the heads of four characteristic features +of the child's psychology—his Imitativeness, his Suggestibility, his +Love of Power, and his acute though limited Reasoning Faculties. I +feel that some such brief examination is necessary if we are to +understand correctly the ætiology of some of the most troublesome +disorders of childhood, such as enuresis, anorexia, dyspepsia, or +constipation, disorders in which the nervous element is perhaps to-day +not sufficiently emphasised. +<span class="pagenum">Page 15<a name="Page_15" id="Page_15"></a></span> +Finally, we can evolve a kind of nursery +psycho-therapeutics—a subject which is not only of fascinating +interest in itself, but which repays consideration by the success +which it brings to our efforts to cure and control.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 16<a name="Page_16" id="Page_16"></a></span></p> +<h3>CHAPTER II</h3> + +<h3>OBSERVATIONS IN THE NURSERY</h3> + +<div class="figcenter"> <br />(<i>a</i>) <span class="subhead">The Imitativeness of the Child</span><br /> </div> + +<p>It is in the second and third years of the child's life that the +rapidity of the development of the mental processes is most apparent, +and it is with that age that we may begin a closer examination. At +first sight it might seem more reasonable to adopt a strictly +chronological order, and to start with the infant from the day of his +birth. Since, however, we can only interpret the mind of the child by +our knowledge of our own mental processes, the study of the older +child and of the later stages is in reality the simpler task. The +younger the infant, the greater the difficulties become, so that our +task is not so much to trace the development of a process from simple +and early forms to those which are later and more complex, as to +follow a track which is comparatively plain in later childhood, but +grows faint as the beginnings of life are approached.</p> + +<p>At the age, then, of two or three the first quality of the child which +may arrest our attention is his extreme imitativeness. Not that the +imitation on his part is in any way conscious; but like a +<span class="pagenum">Page 17<a name="Page_17" id="Page_17"></a></span> +mirror he reflects in every action and in every word all that he sees and hears +going on around him. We must recognise that in these early days his +words and actions are not an independent growth, with roots in his own +consciousness, but are often only the reflection of the words and +actions of others. How completely speech is imitative is shown by the +readiness with which a child contracts the local accent of his +birthplace. The London parents awake with horror to find their baby an +indubitable Cockney; the speech of the child bred beyond the Tweed +proclaims him a veritable Scot. Again, some people are apt to adopt a +somewhat peremptory tone in addressing little children. Often they do +not trouble to give to their voices that polite or deferential +inflection which they habitually use when speaking to older people. +Listen to a party of nurses in the Park addressing their charges. As +if they knew that their commands have small chance of being obeyed, +they shout them with incisive force. "Come along at once when I tell +you," they say. And the child faithfully reflects it all back, and is +heard ordering his little sister about like a drill sergeant, or +curtly bidding his grandmother change her seat to suit his pleasure. +If we are to have pretty phrases and tones of voice, mothers must see +to it that the child habitually hears no other. Again, mothers will +complain that their child is deaf, or, at any rate, that he has the +bad habit of responding to all remarks addressed to him by saying, +"What?" or, worse still, "Eh?" Often +enough the reason that he does so is not +<span class="pagenum">Page 18<a name="Page_18" id="Page_18"></a></span> +that the child is deaf, nor that he is particularly slow to +understand, but simply that he himself speaks so indistinctly that no +matter what he says to the grown-up people around him, they bend over +him and themselves utter the objectionable word.</p> + +<p>We all hate the tell-tale child, and when a boy comes in from his walk +and has much to say of the wicked behaviour of his little sister on +the afternoon's outing, his mother is apt to see in this a most horrid +tendency towards tale-bearing and currying of favour. She does not +realise that day by day, when the children have come in from their +walk, she has asked nurse in their hearing if they have been good +children; and when, as often happens, they have not, the nurse has +duly recounted their shortcomings, with the laudable notion of putting +them to shame, and of emphasising to them the wickedness of their +backsliding—and this son of hers is no hypocrite, but speaks only, as +all children speak, in faithful reproduction of all that he hears. +Those grown-up persons who are in charge of the children must realise +that the child's vocabulary is their vocabulary, not his own. It is +unfortunate, but I think not unavoidable, that so often almost the +earliest words that the infant learns to speak are words of reproof, +or chiding, or repression. The baby scolds himself with gusto, +uttering reproof in the very tone of his elders: "No, no," "Naughty," +or "Dirty," or "Baby shocked."</p> + +<p>Speech, then, is imitative from the first, if we except the early baby +sounds with reduplication +<span class="pagenum">Page 19<a name="Page_19" id="Page_19"></a></span> +of consonants to which in course of time definite meaning becomes +attached, as "Ba-ba," "Ma-ma," "Na-na," +"Ta-ta," and so forth. Action only becomes imitative at a somewhat +later stage. The first purposive movements of the child's limbs are +carried out in order to evoke tactile sensations. He delights to +stimulate and develop the sense of touch. At first he has no knowledge +of distance, and his reach exceeds his grasp. He will strain to touch +and hold distant objects. Gradually he learns the limitations of +space, and will pick up and hold an object in his hand with precision. +Often he conveys everything to his mouth, not because his teeth are +worrying him, or because he is hungry, as we hear sometimes alleged, +but because his mouth, lips, and tongue are more sensitive, because +more plentifully furnished with the nerves of tactile sensation. By +constant practice the sense of touch and the precision of the movement +of his hands are slowly developed, and not these alone, for the child +in acquiring these powers has developed also the centres in the brain +which control the voluntary movements. When the child can walk he +continues these grasping and touching exercises in a wider sphere. As +the child of fifteen or eighteen months moves about the room, no +object within his reach is passed by. He stretches out his hand to +touch and seize upon everything, and to experience the joy of +imparting motion to it. The impulse to develop tactile sensation and +precision in the movements of his hands compels him with irresistible +force. It is foolish to attempt to +<span class="pagenum">Page 20<a name="Page_20" id="Page_20"></a></span> +repress it. It is foolish, because it is a necessary phase in his development, and moreover +a passing phase. No doubt it is annoying to his elders while it lasts, but the +only wise course is to try to thwart as little as we can his +legitimate desire to hold and grasp the objects, and even to assist +him in every way possible. But the mother must assist him only by +allowing free play to his attempts. To hand him the object is to +deprive the exercise of most of its value. Incidentally she may teach +him the virtue of putting things back in their proper places, an +accomplishment in which he will soon grow to take a proper pride. If +she attempts continually to turn him from his purpose, reproving him +and snatching things from him, she prolongs the grasping phase beyond +its usual limits. And she does a worse thing at the same time. Lest +the quicker hands of his nurse should intervene to snatch the prize +away before he has grasped it, he too learns to snatch, with a sudden +clumsy movement that overturns, or breaks, or spills. If left to +himself he will soon acquire the dexterity he desires. He may overturn +objects at first, or let them fall, but this he regards as failure, +which he soon overcomes. A child of twenty months, whose development +in this particular way has not been impeded by unwise repression, will +pick out the object on which he has set his heart, play with it, +finger it, and replace it, and he will do it deliberately and +carefully, with a clear desire to avoid mishap. Dr. Montessori, who +has developed into a system the art of teaching young children to +learn precision +<span class="pagenum">Page 21<a name="Page_21" id="Page_21"></a></span> +of movement and to develop the nerve centres which +control movement, tells in her book a story which well illustrates +this point.<a name="FNanchor_1_1" id="FNanchor_1_1" /><a href="#Footnote_1_1" class="fnanchor">[1]</a></p> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1" /><a href="#FNanchor_1_1"> +<span class="label">[1]</span></a> <i>The Montessori Method</i>, pp. 84, 85.</p></div> + +<p>"The directress of the Casa del Bambini at Milan constructed under one +of the windows a long, narrow shelf, upon which she placed the little +tables containing the metal geometric forms used in the first lesson +in design. But the shelf was too narrow, and it often happened that +the children in selecting the pieces which they wished to use would +allow one of the little tables to fall to the floor, thus upsetting +with great noise all the metal pieces which it held. The directress +intended to have the shelf changed, but the carpenter was slow in +coming, and while waiting for him she discovered that the children had +learned to handle these materials so carefully that in spite of the +narrow and sloping shelf, the little tables no longer fell to the +ground. The children, by carefully directing their movements, had +overcome the defect in this piece of furniture."</p> + +<p>By slow degrees the child learns to command his movements. If his +efforts are aided and not thwarted, before he is two years old he will +have become capable of conducting himself correctly, yet with perfect +freedom. The worst result of the continual repression which may be +constantly practised in the mistaken belief that the grasping phase is +a bad habit which persistent opposition will eradicate, is the nervous +unrest and irritation which it produces in the child. A passionate fit +<span class="pagenum">Page 22<a name="Page_22" id="Page_22"></a></span> +of crying is too often the result of the thwarting of his nature, and +the same process repeated over and over again, day by day, almost hour +by hour, is apt to leave its mark in unsatisfied longing, +irritability, and unrest. Above all, the child requires liberty of +action.</p> + +<p>We have here an admirable example of the effect of environment in +developing the child's powers. A caged animal is a creature deprived +of the stimulus of environment, and bereft therefore to a great extent +of the skill which we call instinct, by which it procures its food, +guarantees its safety from attack, constructs its home, cares for its +young, and procreates its species. If, metaphorically speaking, we +encircle the child with a cage, if we constantly intervene to +interpose something between him and the stimulus of his environment, +his characteristic powers are kept in abeyance or retarded, just as +the marvellous instinct of the wild animals becomes less efficient in +captivity.</p> + +<p>The grasping phase is but a preliminary to more complex activities. +Just as in schooldays we were taught with much labour to make +pot-hooks and hangers efficiently before we were promoted to real +attempts at writing, so before the child can really perform tasks with +a definite meaning and purpose, he must learn to control the finer +movements of his hands. Once the grasping phase, the stage of +pot-hooks, is successfully past—and the end of the second year in a +well-managed child should see its close—the child sets himself with +enthusiasm to wider tasks. To him washing and dressing, fetching +<span class="pagenum">Page 23<a name="Page_23" id="Page_23"></a></span> +his shoes and buttoning his gaiters, all the processes of his simple +little life, should be matters of the most enthralling interest, in +which he is eager to take his part and increasingly capable of doing +so. In the Montessori system there is provided an elaborate apparatus, +the didactic material, designed to cultivate tactile sensation and the +perception of sense stimuli. It will generally suffice to advise the +mother to make use of the ordinary apparatus of the nursery. The +imitativeness of the young child is so great that he will repeat in +almost every detail all the actions of his nurse as she carries out +the daily routine. At eighteen months of age, when the electric light +is turned on in his nursery, the child will at once go to the curtains +and make attempts to draw them. At the same age a little girl will +weigh her doll in her own weighing-machine, will take every precaution +that the nurse takes in her own case, and will even stoop down +anxiously to peer at the dial, just as she has seen her mother and +nurse do on the weekly weighing night. But at a very early age +children appreciate the difference between the real and the +make-believe. They desire above all things to do acts of real service. +At the age of two a child should know where every article for the +nursery table is kept. He will fetch the tablecloth and help to put it +in place, spoons and cups and saucers will be carried carefully to the +table, and when the meal is over he will want to help to clear it all +away. All this is to him a great delight, and the good nurse will +encourage it in the children, because she sees that in doing so they +gain quickness and dexterity and +<span class="pagenum">Page 24<a name="Page_24" id="Page_24"></a></span> +poise of body. The first purposive +movements of the child should be welcomed and encouraged. It is +foolish and wrong to repress them, as many nurses do, because the +child in his attempts gets in the way, and no doubt for a time delays +rather than expedites preparations. The child who is made to sit +immobile in his chair while everything is done for him is losing +precious hours of learning and of practice. It is useless, and to my +mind a little distasteful, to substitute for all this wonderful child +activity the artificial symbolism of the kindergarten school in which +children are taught to sing songs or go through certain semi-dramatic +activities which savour too much of a performance acquired by precise +instruction. If such accomplishments are desired, they may be added +to, but they must not replace, the more workaday activities of the +little child. The child whose impulses towards purposive action are +encouraged is generally a happy child, with a mind at rest. When those +impulses are restrained, mental unrest and irritability are apt to +appear, and toys and picture books and kindergarten games will not be +sufficient to restore his natural peace of mind.</p> + + +<div class="figcenter"> <br />(<i>b</i>) <span class="subhead">The Suggestibility of the Child</span><br /> </div> + +<p>We may pass from considering the imitativeness of the child to study a +second and closely related quality, his suggestibility. His conception +of himself as a separate individual, of his ego, only gradually +emerges. It is profoundly modified by ideas +<span class="pagenum">Page 25<a name="Page_25" id="Page_25"></a></span> +derived from those around +him. Because of his lack of acquired experience, there is in the child +an extreme sensitiveness to impressions from outside. Take, for +example, a matter that is sometimes one of great difficulty, the +child's likes and dislikes for food. Many mothers make complaint that +there are innumerable articles of diet which the child will not take: +that he will not drink milk, or that he will not eat fat, or meat, or +vegetables, or milk puddings. There are people who believe that these +peculiarities of taste correspond with idiosyncrasies of digestion, +and that children instinctively turn from what would do them harm. I +do not believe that there is much truth in this contention. If we +watch an infant after weaning, at the time when his diet is gradually +being enlarged to include more solid food, with new and varied +flavours, we may see his attention arrested by the strange sensations. +With solid or crisp food there may be a good deal of hesitation and +fumbling before he sets himself to masticate and swallow. With the +unaccustomed flavour of gravy or fruit juice there may be seen on his +face a look of hesitation or surprise. In the stolid and placid child +these manifestations are as a rule but little marked, and pleasurable +sensations clearly predominate. With children of more nervous +temperament it is clear that sensations of taste are much more acute. +Even in earliest infancy, children have a way of proclaiming their +nervous inheritance by the repugnance which they show to even trifling +changes in the taste or composition of their food. We see +<span class="pagenum">Page 26<a name="Page_26" id="Page_26"></a></span> +the same sensitiveness in their behaviour to medicines. The mixture which one +child will swallow without resentment, and almost eagerly, provokes +every expression of disgust from another, or is even vomited at once. +In piloting the child through this phase, during which he starts +nervously at all unaccustomed sensations and flavours, the attitude of +mother and nurse is of supreme importance. It is unwise to attempt +force; it is equally unwise, by excessive coaxing, cajoling, and +entreaty, to concentrate the child's attention on the matter. If +either is tried every meal is apt to become a signal for struggling +and tears. The phase, whether it is short or long continued, must be +accepted as in the natural order of things, and patience will see its +end. The management of this symptom,—refusal of food and an +apparently complete absence of desire for food,—which is almost the +commonest neurosis of childhood, will be dealt with later. Here it is +mentioned because I wish to emphasise that if too much is made of a +passing hesitation over any one article of food, if it becomes the +belief of the mother or nurse that a strong distaste is present, then +if she is not careful her attitude in offering it, because she is +apprehensive of refusal, will exert a powerful suggestion on the +child's mind. Still worse, it may cause words to be used in the +child's hearing referring to this peculiarity of his. By frequent +repetition it becomes fixed in his mind that this is part of his own +individuality. He sees himself—and takes great pleasure in the +thought—as a strange child, who by these peculiarities creates +<span class="pagenum">Page 27<a name="Page_27" id="Page_27"></a></span> +considerable interest in the minds of the grown-up people around him. +When the suggestion takes root it becomes fixed, and as likely as not +it will persist for his lifetime. It may be habitually said of a child +that, unlike his brothers and sisters, he will never eat bananas, and +thereafter till the day of his death he may feel it almost a physical +impossibility to gulp down a morsel of the offending fruit. So, too, +there are people who can bolt their food with the best of us, who yet +declare themselves incapable of swallowing a pill.</p> + +<p>Another example of the force of suggestion, whether unconscious or +openly exercised by speech, is given us in the matter of sleep. Among +adults the act of going to bed serves as a powerful suggestion to +induce sleep. Seldom do we seek rest so tired physically that we drop +off to sleep from the irresistible force of sheer exhaustion. Yet as +soon as the healthy man whose mind is at peace, whose nerves are not +on edge, finds himself in bed, his eyes close almost with the force of +a hypnotic suggestion, and he drops off to sleep. With some of us the +suggestion is only powerful in our own bed, that on which it has acted +on unnumbered nights. We cannot, as we say, sleep in a strange bed. It +is suggestion, not direct will power, that acts. No one can absolutely +will himself to sleep. In insomnia it is the attempt to replace the +unconscious auto-suggestion by a conscious voluntary effort of will +that causes the difficulty. A thousand times in the night we resolve +that now we <i>will</i> sleep. If we could but cease to make these fruitless efforts, +<span class="pagenum">Page 28<a name="Page_28" id="Page_28"></a></span> +sleep might come of itself and the suggestion or habit be re-established.</p> + +<p>In little children the suggestion of sleep, provoked by being placed +in bed, sometimes acts very irregularly. Often it may succeed for a +week or two, and then some untoward happening breaks the habit, and +night after night, for a long time, sleep is refused. The wakeful +child put to bed, resents the process, and cries and sobs miserably, +to the infinite distress of his mother. It then becomes just as likely +that the child will connect his bed in his mind, not with rest and +sleep, but with sobbing and crying on his part, and mingled entreaties +and scoldings from his nurse or mother. An important part in this +perversion of the suggestion is played by the attitude of the person +who puts the child to bed. Often the nurse is uniformly successful, +while the mother, who is perhaps more distressed by the sobbing of the +child, as consistently fails, because she has been unable to hide her +apprehension from him, and has conveyed to his mind a sense of his own +power.</p> + +<p>Just in the same way, grown-up people, filled with anxiety because of +the helplessness of the young child, unable to divest their minds of +the fears of the hundred and one accidents that may befall, or that +within their own experience have befallen, a little child at one time +or another, unconsciously make unwise suggestions which fill his mind +with apprehension and terror. They do not like their children to show +fear of animals. Nor would they if it were not that their own +apprehension that the child may be hurt communicates +<span class="pagenum">Page 29<a name="Page_29" id="Page_29"></a></span> +itself to him. The child is not of himself afraid to fall, it is they who suffer the +anxiety and show it by treating the fall as a disaster. The child is +not of himself afraid to be left alone in a room. It is they who sap +his confidence in himself, because they do not venture to leave him +out of their sight, from a nameless dread of what may happen. A little +girl cut her finger and ran to her nurse, pleased and interested: +"See," she said, seeing it bleed, "fingers all jammy." Only when the +nurse grasped her with unwise expressions of horror did she break into +cries of fear. A town-bred nurse, who is afraid of cows, will make +every country walk an ordeal of fear for the children.</p> + +<p>Every mother must be made to realise the ease with which these +unconscious suggestions act upon the mind of the little child, and +should school herself to be strong to make her child strong, and to +see to it that all this suggestive force is utilised for good and not +for evil.</p> + +<p>It is upon this susceptibility to suggestion that a great part of his +early education reposes. No one who is incapable of profiting by this +natural disposition of the child can be successful in her management +of him. Turn where you will in his daily life the influence of this +force of suggestion is clearly apparent. The child does without +questioning that which he is confidently expected to do. Thus he will +eat what is given him, and sleep soundly when he is put to bed if only +the appropriate suggestion and not the contrary is made to him. Again +we have seen that a perversion of suggestion of this +<span class="pagenum">Page 30<a name="Page_30" id="Page_30"></a></span> +sort is a common source of constipation in early childhood. If the child's +attention is directed towards the difficulty, if he is urged or ordered or +appealed to to perform his part, if failure is looked upon as a serious +misfortune, the bowels may remain obstinately unmoved. In children as +in adults a too great concentration of attention inhibits the action +of the bowels, and constipation, in many persons, is due to the +attempt to substitute will power for the force of habitual suggestion. +No matter what other treatment we adopt, the mother must be careful to +hide from the child that his failure is distressing to her. A cheerful +optimism which teaches him to regard himself as one who is +conspicuously regular in his habits, and who has a reputation in this +respect to live up to is sure to succeed. To talk before him of his +habitual constipation, and to worry over the difficulty, is as surely +to fail. In the same way unwise suggestion can interfere with the +passing of water at regular and suitable intervals. There are children +who constantly desire to pass water on any occasion, which is +conspicuously inappropriate, because their attention has been +concentrated on the sensations in the bladder. Often enough when at +great inconvenience opportunity has been found, the desire has passed +away, and all the trouble has proved needless. It is not too much to +say that every occupation and every action of the day can be made +delightful or hateful to the child, according to the suggestion with +which it is presented and introduced. Dressing and undressing, eating +and drinking, +<span class="pagenum">Page 31<a name="Page_31" id="Page_31"></a></span> +bathing, washing, the putting away of toys, even going +to bed, can be made matters of enthralling interest or delight, or a +subject for tears and opposition, according to the bias which is given +to the child's mind by the words, attitude, and actions of nurses and +mothers.</p> + +<p>Here we approach very near to the heart of the subject. Stripped of +all that is not essential we see the problem of the management of +children reduced to the interplay between the adult mind and the mind +of the receptive suggestible child. That which is thought of and +feared for the child, that he rapidly becomes. Placid, comfortable +people who do not worry about their children find their children +sensible and easy to manage. Parents who take a pride in the daring +and naughty pranks of their children unconsciously convey the +suggestion to their minds that such conduct is characteristic of them. +Nervous and apprehensive parents who are distressed when the child +refuses to eat or to sleep, and who worry all day long over possible +sources of danger to him, are forced to watch their child acquire a +reputation for nervousness, which, as always, is passively accepted +and consistently acted up to. Differences in type, determined by +hereditary factors, no doubt, exist and are often strongly marked. Yet +it is not untrue to say that variations in children, dependent upon +heredity, show chiefly in the relative susceptibility or +insusceptibility of the child to the influences of environment and +management. It is no easy task to distinguish between the nervous +child and the child of the +<span class="pagenum">Page 32<a name="Page_32" id="Page_32"></a></span> +nervous mother, between the child who +inherits an unusually sensitive nervous system and the child who is +nervous only because he breathes constantly an atmosphere charged with +doubt and anxiety.</p> + + +<div class="figcenter"> <br />(<i>c</i>) <span class="subhead">The Child's Love of Power</span><br /> </div> + +<p>Let us study briefly a third quality of the child which, for want of a +better name, I have called after the ruling passion of mankind, his +love of power. Perhaps it would be better to call it his love of being +in the centre of the picture. It is his constant desire to make his +environment revolve around him and to attract all attention to +himself. Somewhat later in life this desire to attract attention, at +all costs, is well seen in the type of girl popularly regarded as +hysterical. The impulse is then a morbid and debased impulse; in the +child it is natural and, within limits, praiseworthy. A girl of this +sort, who feels that she is not likely to attract attention because of +any special gifts of beauty or intellect which she may possess, +becomes conscious that she can always arouse interest by the severity +of her bodily sufferings. The suggestion acts upon her unstable mind, +and forthwith she becomes paralysed, or a cripple, or dumb, presenting +a mimicry or travesty of some bodily ailment with which she is more or +less familiar. "Hysterical" girls will even apply caustic to the skin +in order to produce some strange eruption which, while it sorely +puzzles us doctors, will excite widespread interest and commiseration. +Now little +<span class="pagenum">Page 33<a name="Page_33" id="Page_33"></a></span> +children will seldom carry their desire to attract +attention so far as to work upon the feelings of their parents by +simulating disease. They have not the necessary knowledge to play the +part, and even if they make the attempt, complaining of this or that +symptom which they notice has aroused the interest of their elders, +the simulation is not likely to be so successful as to deceive even a +superficial observer. But within the limits of their own powers, +children are past masters in attracting attention. The little child is +unable to take part in any sustained conversation; most of his +talking, indeed, is done when he is alone, and is addressed to no one +in particular. But he knows well that by a given action he can produce +a given reaction in his mother and nurse. A great part of what is said +to him—too great a part by far—comes under the category of reproof +or repression. He is forbidden to do this or that, coaxed, cajoled, +threatened long before he is old enough to understand the meaning of +the words spoken, although he knows the tone in which they are uttered +and loves to produce it at will. How he enjoys it all! Watch him draw +near the fire, the one place that is forbidden him. He does not mean +to do himself harm. He knows that it is hot and would hurt him, but +for the time being he is out of the picture and he is intent on +producing the expected response, the reproof tone from his mother +which he knows so well. He approaches it warily, often anticipating +his mother's part and vigorously scolding himself. He desires nothing +more than that his mother should repeat the reproof, forbidding +<span class="pagenum">Page 34<a name="Page_34" id="Page_34"></a></span> +him a dozen times. The mind of all little children tends easily to work in a +groove. It delights in repetition and it evoking not the unexpected +but the expected. If his sport is stopped by his mother losing +patience and removing him bodily from the danger zone, his sense of +impotence finds vent in passionate crying. But if his mother takes no +notice, the sport soon loses its savour. He is conscious that somehow +or other it has fallen flat, and he flits off to other employment.</p> + +<p>Mothers will complain that children seem to take a perverse pleasure +in evoking reproof, appeals, entreaties, and exhortations. A small boy +of four who had several times repeated the particular sin to which his +attention had been directed by the frequency of his mother's warnings +and entreaties, finding that on this occasion she had decided to take +no notice, approached her with a troubled face: "Are you not angry?" +he said; "are you not disappointed?" In reality the naughty child is +often only the child who has become master of his mother's or his +nurse's responses, and can produce at will the effect he desires. The +idea that the child possesses a strong will, which can and must be +broken by persistent opposition, is based upon this tendency of the +child. It is an entire misconception of the situation: Strength of +will and fixity of purpose are among the last powers which the human +mind develops. In little children they are conspicuously absent. What +appears to us as a fixed and persistent desire to perform a definite +action in spite of all we can say or do, is often no more than +<span class="pagenum">Page 35<a name="Page_35" id="Page_35"></a></span> +the desire to produce the familiar tones of reproof, to traverse again the +familiar ground, to attract attention and to find himself again the +centre of the picture. If no one pays any attention and no one +reproves, he soon gives up the attempt. If too much is made of any one +action of the child, a strong impression is made on his mind and he +cannot choose but return to it again and again.</p> + +<p>This little drama of the fireplace may teach us a great deal in the +management of children. The wise mother and nurse will find a hundred +devices to catch the child's attention and lure him away from the +danger zone without the incident making any impression on his mind at +all, and will not call attention to it by repeated reproofs or +warnings which will certainly lead him straight back to the spot.</p> + +<p>In matters of greater moment the same impulse to oppose the will of +those around him is seen. In considering the point of the child's +susceptibility to suggestion, we have mentioned the refusal of sleep +and the refusal of food. In both it is possible to detect the +influence of this pronounced force of opposition. As the child lies +sobbing or screaming in bed, every new approach to him, every fresh +attempt at pacification, renews the force of his opposition in a +crescendo of sound. But it is in his refusal of food that the child is +apt to find his chief opportunity. Meal-times degenerate into a +struggle. There at least he can show his complete mastery of the +situation. No one can swallow his food for him, and he knows it. He +can clench his teeth and shake his head and obstinately refuse every +morsel offered. +<span class="pagenum">Page 36<a name="Page_36" id="Page_36"></a></span> +He can hold food in his mouth for half an hour at a +time and remain deaf to all the appeals of his helpless nurse. If she +tries force, he quells the attempt by a storm of crying. If she +declines upon entreaty and coaxing, he will not be persuaded. It is +the little scene of the fireplace over again. The attempts at force or +the attempts at persuasion, by making much of it, have concentrated +the attention of the child upon the difficulty, and have taught him +his own power to dominate the situation.</p> + +<p>It is right that parents should realise that the disturbing and +irritating element in the child's environment is nearly always +provided by the intrusion of the adult mind and its contact with the +child's. Some supervision and some intrusion, therefore, is of course +absolutely necessary, but the best-regulated nursery is that in which +it is least evident. Something is definitely wrong if a child of two +years will not play for half an hour at a time happily and busily in a +room by himself. It is an even better test if the child will play +amicably by himself with nurse or mother in the room, without the two +parties crossing swords on a single occasion, without reproof or +repression on the one side or undue attempts to attract attention on +the other. If the child is entirely dependent upon the participation +of grown-up persons in his pursuits, then not only do those pursuits +lose much of their educative force, but they become a positive source +of danger because of the constant interplay of personality with +personality. The child who, seated on the ground, will play with his +toys by himself, rises +<span class="pagenum">Page 37<a name="Page_37" id="Page_37"></a></span> +with a brain that is stimulated but not +exhausted. Only very rarely do we find that solitary play, or play +between children, is too exciting. In older children of very quick +intelligence and nervous temperament we occasionally find that the +pace which they themselves set is too exciting or exhausting. I recall +a little boy of seven, an only child of particularly wise and +thoughtful parents, who was brought to me with the complaint that he +exhausted himself utterly both in body and mind by the intense nervous +energy which he threw into his pursuits. For instance, he had been +interested in the maps illustrating the various fronts in the European +War, with which the walls of his father's study were hung, and +although left entirely by himself he had become intensely excited and +exhausted by the eagerness with which he had spent a whole morning, +with a wealth of imaginative force, in drawing a map of the garden of +his house and converting it into the likeness of a war map, filled +with imaginary Army Corps. Such excessive expenditure of nervous force +is unusual even in older children, and as in this case is found +usually only when there is a pronounced nervous inheritance. In little +children in the nursery, solitary play or play between themselves +seldom produces nervous exhaustion. It is quite otherwise when the +child is dependent to a too great extent upon the participation of +adults. It is almost impossible for the mother and nurse not to take +the leading part in the exchange of ideas, and no matter what may be +their good intentions, the pace set is apt to +<span class="pagenum">Page 38<a name="Page_38" id="Page_38"></a></span> +be too great. Environment, without the intrusion of the adult mind, is best able to +adjust the necessary stimulus and produce development without +exhaustion. Play with grown-up persons, the reading aloud of story +books, the showing of pictures, and so forth, undoubtedly have their +own importance, but they should be confined within strict limits and +to a definite hour in the daily routine. There is sometimes too great +a tendency for parents to make playthings of their little children. +Save at stated times, they must curb their desire to join in their +games, to gather them in their arms, to hold them on their knee, while +they stimulate their minds by a constant succession of new +impressions. With an only child, whose existence is the single +preoccupation of the nurse and mother, and, often enough, of the +father as well, it is difficult to avoid this fault. Yet, if wisdom is +not learnt, the damage to the child may be distressingly serious. He +rapidly grows incapable of supporting life without this excessive +stimulation. Without the constant society and attention of a grown +person, he feels himself lost. He cannot be left alone, and yet cannot +enjoy the society he craves. He grows more and more restless, +dominating the whole situation more and more, constantly plucking at +his nurse's skirts, perversely refusing every new sensation that is +offered him to still his restlessness for a moment. The result of all +this stimulation is mental irritability and exhaustion, which in turn +is often the direct cause of refusal of food, dyspepsia, wakefulness, +and excessive crying.</p> + +<p><span class="pagenum">Page 39<a name="Page_39" id="Page_39"></a></span> +The devices by which children will attract to themselves the +attention of their elders, and which, if successful, are repeated with +an almost insane persistence, take on the most varied forms. Sometimes +the child persistently makes use of an expression, or asks questions, +which produce a pleasant stir of shocked surprise and renewed reproofs +and expostulations. One little boy shouted the word "stomachs" with +unwearied persistence for many weeks together. A little girl dismayed +her parents and continued in spite of all they could do to prevent her +to ask every one if they were about to pass water.</p> + +<p>Disorders of conduct of this sort are not really difficult to control. +Suitable punishment will succeed, provided also that the child is +deprived of the sense of satisfaction which he has in the interest +which his conduct excites. His behaviour is only of importance because +it indicates certain faults in his environment and a certain element +of nervous unrest and overstrain.</p> + +<p>The young child demands from his environment that it should give him +two things—security and liberty. He must have security from shocks to +his nervous system. It is true that from the greater shocks the +children of the well-to-do are as a rule carefully guarded. No one +threatens or ill-uses them. They are not terrified by drunken brawls +or scenes of passion. They are not made fearful by the superstitions +of ignorant people. Nevertheless, by the summation of stimuli little +emotions constantly repeated can have effects no less grave +<span class="pagenum">Page 40<a name="Page_40" id="Page_40"></a></span> +upon their nervous system. From this constantly acting irritation the child +needs security. In the second place, he requires liberty to develop +his own initiative, which should be stimulated and sustained and +directed. Without liberty and without security conduct cannot fail to +become abnormal.</p> + + +<div class="figcenter"> <br />(<i>d</i>) <span class="smcap">The Reasoning Power of the Child</span><br /> </div> + +<p>Before we proceed to a closer examination of the various symptoms of +nervous unrest in detail, we may very briefly consider the scope and +power of the child's understanding. As a rule I am sure that it is +grossly underestimated. The mental processes of the child are far +ahead of his power of speech. The capacity for understanding speech is +well advanced, and an appeal to reason is often successful while the +child is still powerless to express his own thoughts in words. Because +he cannot so express himself there is a tendency to underestimate the +acuteness of his reasoning, to talk down to him, and to imagine that +he can be imposed upon by any fiction which seems likely to suit the +purpose of the moment. A child of eighteen months is not too young to +be talked to in a quiet, straightforward, sensible way. Only if he is +treated as a reasonable being can we expect his reasoning faculties to +develop. Children dislike intensely the unexplained intervention of +force. If a pair of scissors, left by an oversight lying about, has +been grasped, the first impulse of the mother is to snatch the danger +hurriedly from the child's hands, and +<span class="pagenum">Page 41<a name="Page_41" id="Page_41"></a></span> +her action will generally be +followed by resistance and a storm of weeping. She will do better to +approach him quietly, telling him that scissors hurt babies, and show +him where to place them out of harm's way. Watch a child at play after +his midday meal. He has been out in his perambulator half the morning, +and for the other half has been deep in his midday sleep. Now that +dinner is over he is for a moment master of his time and busily +engaged in some pursuit dear to his heart. At two o'clock inexorable +routine ordains that he must again be placed in the perambulator and +wheeled forth on a fresh expedition. If the nurse does not know her +business she will swoop down upon him, place him on her knee, and +begin to envelop his struggling little body in his outdoor clothes, +scolding his naughtiness as he kicks and screams. If she has a way +with children she will open the cupboard door and call on him to help +find his gaiters and his shoes because it is time for his walk. In a +moment he will leave his toys, forgetting all about them in the joy of +this new activity.</p> + +<p>If the reason for things is explained to children they grow quick to +understand quite complicated explanations. A little girl, not yet two, +was playing with her Noah's Ark on the dining-room table with its +polished surface. The mother interposed a cloth, explaining that the +animals would scratch the table if the cloth were not there. Within a +few minutes the child twice lifted the cloth, peering under it and +saying, "Not scratch table." Yet +<span class="pagenum">Page 42<a name="Page_42" id="Page_42"></a></span> +how often do we find +facetiously-minded persons confound their reasoning and confuse their +judgment by foolish speeches and cock-and-bull tales, which, just +because of their foolishness, seem to them well adapted to the infant +intelligence.</p> + +<p>An attempt to deceive the child is almost always wrong, and because of +our tendency to underestimate the child's intelligence it generally +fails. If a little girl has a sore throat, and the doctor comes to see +her, she knows quite well that she is the prospective patient. It is +useless for the mother to begin proceedings by trying to convince her +that this is not so—that mother has a sore throat too. Such a plan +only arouses apprehension, because the child scents danger in the +artifice.</p> + +<p>Closely connected with the reasoning powers of the child is the +difficult question of the growth of his appreciation of right and +wrong, or, to put it in another way, the growth of obedience or +disobedience. Sooner or later the child must learn to obey; on that +there can be no two opinions. Nevertheless, I think there can be no +doubt that far more harm is done by an over-emphasis of authority than +by its neglect. If the nurse or mother is of strong character, and the +authority is exercised persistently and remorselessly, so that the +whole life of the child is dominated, much as the recruit's existence +in the barrack yard is dominated by the drill sergeant, his +independence of nature is crushed. He is certain to become a +colourless and uninteresting child; he runs a grave risk of growing +sly, broken-spirited, and a currier of favour. If a child is ruthlessly +<span class="pagenum">Page 43<a name="Page_43" id="Page_43"></a></span> +punished for disobedience from his earliest years, there +is, it need hardly be said, a grave risk that he will learn to lie to +save his skin. I have seen a few such cases of what I may call the +remorseless exercise of authority, and the result has not been +pleasing. Fortunately, perhaps, not many women have the heart to adopt +this attitude to the waywardness of little children—a waywardness to +which their whole nature compels them by their pressing need to +cultivate tactile sensations, to experiment, and to explore. +Therefore, much more commonly, the authority is exercised +intermittently and capriciously, with the result that the child's +judgment is clouded and confused. Conduct which is received +indulgently or even encouraged at one moment is sternly reprimanded at +another. Every one who has the management of little children must +above all see to it, whatever the degree of stringency in discipline +which they decide to adopt, that their attitude is always consistent. +The less that is forbidden the better, but when the line is drawn it +must be adhered to. If once the child learns that the force which +restrains him can be made to yield to his own efforts, the future is +black indeed. From that day he sets himself to strike down authority +with a success which encourages him to further efforts. I have known a +child of five years terrorise his mother and get his own way by the +threat, "I will go into one of my furies."</p> + +<p>The difficulty of successfully enforcing authority, and of carrying +off the victory if that authority is disputed, should make mothers +wary of drawing +<span class="pagenum">Page 44<a name="Page_44" id="Page_44"></a></span> +too tight a rein. The conflict between parent and +child must always be distressing and must always be prejudicial to the +child, whatever its outcome, whether it brings to him victory or +defeat. He learns from it either an undue sense of power or an undue +sense of helplessness, and the knowledge of neither is to his benefit. +Although frequently worsted in the conflict, nurses will often return +to the attack again and again and hour after hour, restraining, +reproving, forbidding, and even threatening. Nor do they see that they +are really goading the children into disobedience by their misdirected +efforts at enforcing discipline. Reproof, like punishment, loses all +its effect when it is too often repeated, and the child soon takes it +for granted that all he does is wrong, and that grown-up people exist +only to thwart his will, to misunderstand, to reprove, or even to +punish.</p> + +<p>In the nursery the word "naughty" is far too frequently heard. It is +naughty to do this, it is naughty to do that. There is no gradation in +the condemnation, and the child loses all sense of the meaning of the +word. He himself proclaims himself naughty almost with satisfaction: +his doll is naughty, the dog is naughty, his nurse and mother are +naughty, and so forth. In reality the little child is peculiarly +sensitive to blame, if he is not reproof-hardened. It is hardly +necessary to use words of blame at all. If he is asked kindly and +quietly to desist, much as we would address a grown-up person, and +does not, he can be made to feel that his conduct is unpopular by +keeping aloof from him a +<span class="pagenum">Page 45<a name="Page_45" id="Page_45"></a></span> +little, by disregarding him for the time +being, and by indicating to him that he is a troublesome little person +with whom we cannot be bothered.</p> + +<p>Any one who has had much to do with children will realise that, if +wrongly handled, they are apt to take a positive delight in doing what +they conceive to be wrong. There is clearly a delightful element of +excitement in the process of being naughty, of daring and of braving +the wrath to come, with which they are so familiar and for which they +care nothing at all. But the perverseness of which we are now speaking +has a different origin. It arises only when children are reproved, +appealed to, and expostulated with too often and too constantly. +Negativism is a symptom which is common enough in certain mental +disorders. The unhappy patient always does the opposite of what is +desired or expected of him. If he be asked to stand up he will +endeavour to remain seated, or if asked to sit he will attempt to rise +to his feet. Like many other symptoms of nervous disturbance which we +shall study later, this negativistic spirit is often displayed to +perfection by little children when the environment is at fault and +when grown-up people have too freely exercised authority. A mother, +anxious to induce her little son to come to the doctor, and knowing +well that her call to him to enter the room, as he stands hesitating +at the door, will at once determine his retreat to the nursery, has +been heard to say, "Run away, darling, we don't want <i>you</i> here," with +the expected result that the docile child immediately comes +<span class="pagenum">Page 46<a name="Page_46" id="Page_46"></a></span> +forward. To the doctor, that such a device should be practised almost as a +matter of course and that its success should be so confidently +anticipated, should give food for thought. It may shed light on much +that is to follow later in the interview.</p> + +<p>The question of punishment, like that of reproof, is beset with +difficulty. There are fortunately nowadays few educated mothers who +are so foolish as to threaten punishment which they obviously do not +intend to administer and which the child knows they will not +administer. It is clear that punishment must be rare or else the child +will grow habituated to it, and with little children we cannot be +brutal or push punishment to the point of extreme physical pain. It is +more difficult to say, as one is tempted to say, that all punishment +is futile and should be discarded. Probably mothers are like +schoolmasters in that no two schoolmasters and no two mothers obtain +their effects in exactly the same way or by precisely the same means. +Nor do all children accept reproof or submit to punishment in the same +way. Some make light of it and take a pleasure in defying authority. +Others are unduly cast down by the slightest adverse criticism. It is +generally true that extreme sensitiveness to reproof is a sign of a +certain elevation of character. Always we must remember that for a +mother to inflict punishment, whether by causing physical pain or +mental suffering, is to take on her shoulders a certain +responsibility. It is a serious matter if she has misapprehended the +child's act—if the sin was not really a sin, but only some perverted +action, the intention +<span class="pagenum">Page 47<a name="Page_47" id="Page_47"></a></span> +of which was not sinful, but designed for good +in the faulty reasoning of the child. A little girl, in bed with a +feverish cold, was found shivering, with her night-dress wet and +muddy. It was an understanding mother who found that her little +brother, having heard somehow that ice was good for fevered heads, had +brought in several handfuls of snow from the garden, not of the +cleanest, and had offered them to aid his sister's recovery. It need +hardly be said that punishment should always be deliberate. The hasty +slap is nothing else than the motor discharge provoked by the +irritability of the educator, and the child, who is a good observer on +such points, discerns the truth and measures the frailty of his judge.</p> + +<p>The frequent repetition of words of reproof and acts of punishment has +a further disadvantage that the older children are quick to practise +both upon their younger brothers and sisters. There is something wrong +in the nursery where the lives of the little ones are made a burden to +them by the constant repression of the older children. But although +set and artificial punishments are as a general rule to be used but +sparingly, the mother can see to it that the child learns by +experience that a foolish or careless act brings its own punishment. +If, for example, a child breaks his toy, or destroys its mechanism, +she need not be so quick in mending it that he does not learn the +obvious lesson. If the baby throws his doll from the perambulator, in +sheer joy at the experience of imparting motion to it, she need not +prevent him from learning the +<span class="pagenum">Page 48<a name="Page_48" id="Page_48"></a></span> +lesson that this involves also some +temporary separation from it. Throughout all his life he is to learn +that he cannot eat his cake and have it too. The use of rewards is +also beset with difficulties. Their coming must be unexpected and +occasional. They must never degenerate into bribes, to be bargained +for upon condition of good behaviour. Rewards which take the form of +special privileges are best.</p> + +<p>The æsthetic sense of children develops very early. From the very +beginning of the second year they take delight in new clothes, and in +personal adornment of all sorts. They show evident pleasure if the +nursery acquires a new picture or a new wall-paper. They have +pronounced favourites in colours. Even tiny children show dislike of +dirt and all unpleasant things. Personal cleanliness should be clearly +desired by all children. A sense of what is pleasant and what is +unpleasant should be encouraged. Any delay in its appearance is apt to +imply a backwardness in development of mind or of body. Only children +who are tired out by physical illness or by nervous exhaustion will +lie without protest in a dirty condition.</p> + +<p>Affection and the attempt to express affection appear clearly marked +even in the first year. Too much kissing and too much being kissed is +apt to spoil the spontaneity of the child's caresses. We must not, +however, expect to find any trace in the young child of such a complex +quality as unselfishness or self-abnegation. The child's conception of +his own self has but just emerged. It is his single impulse to develop +his own experience and his own +<span class="pagenum">Page 49<a name="Page_49" id="Page_49"></a></span> +powers, and his attitude for many years is summed up in the phrase: +"Me do it." We must not expect him +to resign his toys to the little visitor, or the little visitor to +cease from his efforts to obtain them. In all our dealings with +children we must know what we may legitimately expect from them, and +judge them by their own standards, not by those of adult life. We +cannot expect self-sacrifice in a child, and, after all, when we come +to think of it, obedience is but another name for self-sacrifice. If +the tiny child could possibly obey all the behests that are heaped +upon him in the course of a day by many a nurse and mother, he would +truly be living a life of complete self-abnegation. Surely it is +because the virtue of obedience, the virtue that is proclaimed +proverbially the child's own, is so impossible of attainment that it +is become the subject of so much emphasis. As Madame Montessori has +put it: "We ask for obedience and the child in turn asks for the +moon." Only when we have developed the child's reasoning powers, by +treating him as a rational being, can we expect him deliberately to +defer his wishes to ours, because he has learned that our requests are +generally reasonable.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 50<a name="Page_50" id="Page_50"></a></span></p> +<h3>CHAPTER III</h3> + +<h3>WANT OF APPETITE AND INDIGESTION</h3> + + +<p>The mind of the child is so unstable and yet so highly developed, that +symptoms of nervous disturbance are more frequent and of greater +intensity than in later life. Only rarely and in exceptional cases do +certain symptoms, common in childhood, persist into adult life or +appear there for the first time, and then usually in persons who, if +they are not actually insane, are at least suffering from intense +nervous strain. We have already mentioned the symptom of negativism +and noted its occasional occurrence as an accompaniment of mental +disorder in adult life, and its frequency among children who are +irritable or irritated. Similarly, we may cite the digestive neuroses +of adult life to explain the common refusal of food and the common +nervous vomiting of the second year of life. Thus, for example, there +exists in adult life a disturbance of the nervous system which is +called "anorexia nervosa." A boy of nineteen was brought to the +Out-patient Department of Guy's Hospital suffering from this +complaint. He was little more than a skeleton, unable to stand, hardly +able to sit, and weighing +<span class="pagenum">Page 51<a name="Page_51" id="Page_51"></a></span> +only four and a half stones. His mother, +who came with him, stated that he had always been nervous, and that +lately, after receiving a call to join the army as a recruit, his +appetite, which had for some time been capricious, had completely +disappeared. In spite of coaxing he resolutely refused all food, or +took it only in the tiniest morsels, although at the same time it was +thought that he sometimes took food "on the sly." A careful +examination showed absolutely no sign of bodily disease. He was +admitted to a ward for treatment by hypnotic suggestion, but before +this could be begun he endeavoured to commit suicide by setting fire +to his bed.</p> + +<p>A girl of twenty-four years of age had become almost equally +emaciated. Constant vomiting had persisted for many years and had +defied many attempts at cure. It had even been proposed to perform the +operation of gastro-enterostomy in the belief that some organic +disease existed. In suitable surroundings and with the energetic +support of a good nurse, who spent much time and care in restoring her +balance of mind, the vomiting ceased, and she gained over two stones +in weight. Work was found for her in some occupation connected with +the War, and she left the Nursing Home to undertake this, bearing with +her four pounds which she had abstracted from the purse of another +patient.</p> + +<p>Those who have not opportunities of observing how all-powerful is the +effect of the mind upon the body, and especially perhaps upon the +<span class="pagenum">Page 52<a name="Page_52" id="Page_52"></a></span> +process of digestion, may find it hard to believe that these +distressing symptoms and profound changes in the aspect and nutrition +of the patients were due entirely to mental causes and were symptoms +in accord with the attempted suicide or the theft of the money. In +nervous little children we shall not often find such complex actions +as suicide or theft, although they do occur, but combined with other +evidence of nervousness we shall meet commonly enough with a +persistent setting aside of appetite and refusal of food and with +continuous and habitual vomiting, from nervous causes.</p> + +<p>The experiments of Pawlow and others have explained the dependence of +digestion upon mental states. They show that even before the food is +taken into the mouth, while the meal is still in prospect, there has +been instituted a series of changes in the wall of the stomach, which +gives rise to the so-called psychic secretion of gastric juice. These +changes are preceded by the sensation of appetite, which is evoked not +by the presence of food in the stomach—for the food has not yet been +swallowed—but by the anticipation of it, by the sight and smell of +food, as well as by more complex suggestions, such as the time of day, +the habitual hour, the approach of home, and so forth.</p> + +<p>Emotional states of all sorts—grief, anger, anxiety, or +excitement—put a stop to the process or interfere with its action, so +that the sense of appetite is absent, and the taking of food is apt to +be followed by discomfort or pain or vomiting. No doubt good digestion +leads to a placid mind, but it is +<span class="pagenum">Page 53<a name="Page_53" id="Page_53"></a></span> +equally true that a placid mind is +necessary for good digestion. Therefore we civilised people, living +lives of mental stress and strain, try to increase the suggestive +force of our surroundings and to provoke appetite by all devices +calculated to stimulate the æsthetic sense. The dinner hour is fixed +at a time when all work and, let us hope, all worry is at an end for +the day. The dinner-table is made as pretty as possible, with flowers +and sparkling glass. We are wise to dress for dinner, that with our +working clothes we may put off our working thoughts.</p> + +<p>In the treatment of adult dyspepsia we seldom succeed unless we can +place the mind at rest. We may advise a visit to the dentist and a set +of false teeth, or we may administer a variety of stomach tonics and +sedatives, but if the mind remains filled with nameless fears and +anxieties we shall not succeed.</p> + +<p>In adult life the nervous person when subjected to excessive stress +and strain is seldom free from dyspeptic symptoms of one sort or +another, and what is true of adult life is even more true of +childhood, when the emotions are more poignant and less controlled. +Then tears flow more readily than in later life, and tears are not the +only secretions which lie under the influence of strong emotion. +Emotional states, which would stamp a grown man as a profound +neurotic, are almost the rule in infancy and childhood, and may be +marked by the same physical disturbances—flushing, sweating, or +pallor, by the discharge of internal glandular secretions as well as +by inhibition of appetite, by vomiting, +<span class="pagenum">Page 54<a name="Page_54" id="Page_54"></a></span> +gastric discomfort, or +diarrhoea. Naturally enough, mothers and nurses are wont to demand a +concrete cause for the constant crying of a little child, and +teething, constipation, the painful passage of water, pain in the +head, or colic and indigestion are suggested in turn, and powders, +purges, or circumcision demanded. There can be no doubt that nervous +unrest is capable of producing prolonged dyspepsia in infancy and +childhood—a dyspepsia which, while it obstinately resists all +attempts to overcome it by manipulation of the diet, is very readily +amenable to treatment directed to quiet the nervous system.</p> + +<p>Where a primary dyspepsia exists for any length of time, the growth +and the nutrition of the child is clearly altered for the worse. The +character of the stools, their consistency, smell, and colour, is apt +to be changed because the bacterial context of the bowel has become +abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, +prolapse of the rectum, and infection with thread-worms are common +complications. No doubt children with primary dyspepsia are often +nervous and restless, and the elements of infection and of neurosis +are frequently combined. Yet often we meet with cases in which the +gastric or intestinal disturbance comes near to being a pure neurosis. +The nutrition, then, seldom suffers to any very great extent, or to a +degree in any way comparable to that which is characteristic of +dyspepsia from other causes. Emaciation, wrinkling of the skin, +dryness and falling out of the hair, decay of the teeth, are not as +<span class="pagenum">Page 55<a name="Page_55" id="Page_55"></a></span> +a rule part of the picture of nervous dyspepsia. The child may be slim +and thin and nervous looking, but as a rule he is active enough, with +a good colour and fair muscular tone, so that one has difficulty in +believing the mother's statements, which are yet true enough, as to +the trouble which is experienced in forcing him to eat, or as to the +frequency of vomiting.</p> + +<p>In early childhood the difficulty of the refusal of food often passes +or diminishes when the child learns to feed himself with precision and +certainty. To teach him to do so, it is not wise to devote all our +attention to making him adept at this particular task. The fault is +that the brain centres which control the movements of hands, mouth, +and tongue have not been developed, because his activities in all +directions have not been encouraged. It is much less trouble for a +nurse to feed a little child than to teach him to feed himself, and if +he is not given daily opportunities of practice he will certainly not +learn this particular action. But the fault as a rule lies deeper. The +child who cannot feed himself cannot be taught until fingers and brain +have been developed in the thousand activities of his daily routine, +by which he acquires general dexterity. A child who is still too young +to feed himself is learning the dexterity which is necessary as a +preliminary in every action of the day. If he can carry the tablecloth +and the cups and saucers to the tea-table, imitating in everything the +action of his nurse, it will be strange if he does not also imitate +her in the <span class="pagenum">Page 56<a name="Page_56" id="Page_56"></a></span> +central scene, the actual eating of the food. If, on the +other hand, he is waited upon hand and foot, if he is restrained and +confined, sitting too much passively, now in his perambulator, now in +his high chair, now on his nurse's lap, his imitative faculties and +his tactile dexterity alike remain undeveloped. The child who is slow +in learning to feed himself shows his backward development in every +movement of his body. One may note especially the stiff, +"expressionless" hands, indicating a general neuro-muscular defect. I +have seen many children of eighteen months or two years of age in whom +the movements necessary for efficient mastication and swallowing had +failed to develop satisfactorily. In some a pure sucking movement +persisted, so that when, for example, a morsel of bread or rusk was +put in the child's mouth, it would be held there for many minutes and +submitted only to suction with cheeks and tongue. Attempts to swallow +in such a case are so incoordinate that they give rise frequently to +violent fits of choking, which distress the child and produce +resistance and struggling, while at the same time they alarm the +mother or nurse so much that further attempts to encourage the taking +of solid food are hastily and for a long time abandoned. In this +helpless condition the other factors which tend to develop what we +have called negativism have full play. The want of imitation and the +lack of dexterity is not the sole or perhaps the main cause of the +child's refusal of food and of the apparent want of appetite, but it +is the cause of the failure to learn to feed himself, +<span class="pagenum">Page 57<a name="Page_57" id="Page_57"></a></span> +which places him in a condition which is peculiarly favourable to the operation of +other factors. If only we can teach the child to feed himself, the +difficulties of the situation become much less formidable.</p> + +<p>The first of the factors which encourage the persistent refusal of +food is the extreme susceptibility of the child to suggestion. A +particular article of diet may be refused on one occasion, perhaps in +pique, because another more favoured dish was hoped for or expected, +or perhaps because the taste is not yet familiar. Then if on this +occasion a struggle for the mastery is waged, and a painful impression +is made on the child's mind connecting this particular dish with +struggling and tears, from that day forward the child may persistently +refuse it on every occasion it is offered. Matters are made worse if +the nurse, anticipating refusal, attempts to overcome the resistance +by peremptory orders, or by excessive praise extolling the delicious +flavour with such fervour that the child's suspicions are at once +aroused. Previous experience has made him connect these excessive +praises with articles which have aroused his distaste. If these fads +and fancies on the part of the child are to be avoided, it is +essential that we should do nothing to focus his attention on his +refusal. It is better that his dinner should be curtailed on one +occasion than that taste and appetite should be perverted perhaps for +years. Every nurse or mother should cultivate an off-hand, detached +manner of feeding the child, and should patiently continue +<span class="pagenum">Page 58<a name="Page_58" id="Page_58"></a></span> +to offer the food without uncalled-for comments or exhortations. Let her always +remember the force of suggestion on the child's mind, and that a +confident manner which never questions the child's acceptance will +meet with acceptance, while a hesitating address, from fear of the +impending refusal, will be apt to meet with refusal. Sometimes a still +worse fault manifests itself, when nurse and mother speak before the +child of the smallness of his appetite, and of his persistent refusal +of this or that article of diet. The suggestion then acts still more +powerfully on his mind. He is aware that the whole household is +distressed by his peculiarity, and he grows to identify it with his +own individuality, and to regard himself with some satisfaction as +possessing this mark of distinction. If there is any difficulty of +this sort it is often directly curative to reverse the suggestion and +to speak before him of his improving appetite, and to say that he +begins every day to eat better and better, even if to do so we have to +break a good rule never to say to the child what is not strictly true. +Or once or twice we may take his plate away before he has finished, +saying positively that he has eaten so much that he must eat no more. +If in spite of every care antipathies to certain articles of food +appear and persist, we must be content to bide our time. When the +child grows of an age to reason, we should seize every opportunity to +make him feel that his persistent refusal is a little ridiculous and +childish. Little by little the seed is sown, and will germinate till +one day we shall note with surprise +<span class="pagenum">Page 59<a name="Page_59" id="Page_59"></a></span> +that he has taken of his own accord that which he has neglected +for so long and with such obstinacy.</p> + +<p>But the force which is acting most strongly in producing this refusal +of food is the force of which we have spoken in a previous +chapter—the force which results in negativism, the force which is in +reality the habit of opposition, the love of power, and the desire to +attract attention. Here again the refusal of food, if due to this +cause, is never the sole manifestation of the fault. Just as the delay +in learning to swallow and to chew properly and to feed himself is +part of a general want of dexterity and capacity manifested in all his +actions, so it will seldom happen that the child's anxiety to oppose +is only seen at meal-times. Watch a nervous child in the nursery +before the dinner hour. He is cross and restless and inclined to cry. +The nurse hands him a doll, and he throws it away saying, "No, no +doll." At the same moment he may catch sight of his ball, and it too +is violently rejected, "No, no ball." Everything in turn is treated in +the same way. Finally he falls upon his nurse, crying and beating her +with his hands, saying, "No, no Nurse." If that long-suffering woman +at that moment summons him to dinner, it will be strange indeed if his +attitude is not "No, no dinner," and "No, no" to every mouthful +offered him. How strong this love of opposition may be is illustrated +by the case of a little boy who was brought to me for refusal of food. +Three weeks before, he had been taken in a motor-car to his +grandfather's to midday dinner on Sunday, when his absolute refusal of +food had spoiled the +<span class="pagenum">Page 60<a name="Page_60" id="Page_60"></a></span> +day and had occupied the attention and the +efforts of the whole party. Doubtless he had enjoyed himself, for +three weeks later, when he caught sight of the car which was to bring +him to me, and which he had not seen in the interval, he at once said, +"Not eat my dinner." This child's father told me that the sight or +sound of the preparation of a meal was enough to bring on a paroxysm +of opposition. Now this force of opposition, as we have seen, only +develops into a serious difficulty when the child's own will has been +opposed too much, when authority has been too freely exercised, and +when the child has been urged and entreated and reproved with too +great frequency. His opposition grows with all counter-opposition. And +he is not really naughty, only irritable and restless from the +thwarting of his natural impulses, and unable to express his thoughts +and desires. Negativism will not often confine itself to meal-times. +It will show clearly in all the actions of the child, and to get him +to eat well and freely we must so change our management of him that +negativism disappears or at least diminishes. There is no other way. +No entreaty, no force, no threats of force will ever succeed, but will +only make him worse, and, since negativism is due to mental unrest, +the struggles and crying will only perpetuate the cause. The one way +to banish negativism and overcome the opposition is to cease to +oppose, and to practise this aloofness not so much at meal-times, for +somehow by patience the child must be got to take his food, but in all +our conduct to him. Repression and reproof, and +<span class="pagenum">Page 61<a name="Page_61" id="Page_61"></a></span> +thwarting of the child's will, and coaxing and entreaty must cease. There is no fear +that we shall thereby make the child unduly disobedient. We have +already, in another chapter, decided that negativism is not strength +of will on the part of the child which must be broken, but is the +result of constant attempts to oppose his nature, and the consequent +nervous unrest. If we cease to oppose, the symptoms will tend rapidly +to disappear, the child will become busy and contented and happy in +his play, and we shall hear no more of his refusal of food. If +sometimes it recurs for a week or two, we shall know how to deal with +it.</p> + +<p>In children, as with us, periods of nervous unrest and unhappiness are +apt to recur in a sort of cycle. This cyclical character of mental +disturbance is often a marked feature. We see it in epilepsy and +in what the French have called Folie Circulaire. We see it in the +dipsomaniac, in the intermittency of his craving for drink and of his +periodical outbursts, and we see it in ourselves in those periods of +depression which recur so often, we know not why. Little children too +sometimes get out on the wrong side of their beds, and never get right +the whole long day. Their own experience of the vagaries of mental +states should lead mothers to be indulgent to the children in their +days of cloud and to be particularly careful not to goad them by +well-intentioned efforts into bursts of naughtiness and passion, each +one of which tends to perpetuate the condition and increase the +nervous unrest. We know how closely dependent is the sensation of +<span class="pagenum">Page 62<a name="Page_62" id="Page_62"></a></span> +appetite upon emotional states, and we must do all in our power—and +the task is sometimes one of real difficulty—to keep the child's mind +sufficiently at rest to preserve the healthy desire for food +unimpaired. If there is no sign of appetite, but every sign of +restlessness and irritability, we must seek in the management of the +child until we find the fault.</p> + +<p>If food is taken mechanically and without appetite, if the preliminary +changes in the stomach wall which are necessary for adequate digestion +do not take place, but are inhibited by the mental unrest, the meal is +apt to be followed by gastric pain and discomfort, or, more commonly +with children, the stomach may promptly reject its contents. At the +worst, nervous vomiting of this sort may follow almost every meal, +although, again, it is curious to note how little, comparatively +speaking, the nutrition of the child suffers. The vomiting too, as in +adults, comes very near being a voluntary act, and mothers and nurses +will often remark that they get the impression that it can be +controlled at will. If once the diagnosis is made that the want of +appetite or the vomiting is of nervous origin, the treatment of the +condition is clear. Sedative drugs directed towards quieting the +nervous excitability may be of service, but tonics, appetisers, +laxatives, and drugs with a direct action on the stomach will have but +little effect. Nor is there as a rule anything to be gained by +modifying the diet or by excluding this or that article of food. The +frequency of the vomiting is such that it is apt to have brought +<span class="pagenum">Page 63<a name="Page_63" id="Page_63"></a></span> +discredit one after the other upon almost every article of food which +the child can take, with the result that many useful and necessary +foods have been abandoned for long on the ground that they are the +cause of the dyspepsia. A permanent cure will only be effected when +the faults of environment have been overcome, when the cause of the +nervous unrest has been removed, and when the child's mind is at +peace.</p> + +<p>Nervous vomiting of this kind is not difficult to control, if those in +charge of the children can be made to understand that the cause lies +in the anxiety which they themselves show before the child, increasing +his own apprehension or adding to his sense of power or importance. +Once the child is convinced that his conduct excites no particular +interest, the vomiting soon ceases. In more than one instance, +vomiting which has persisted for many months has stopped at once after +the matter has been fully explained to the parents. In the most +inveterate case of this sort which has come under my notice, the child +was regularly sick as soon as he caught sight of a white cloth being +laid on the table for meals. Yet even this child never vomited when he +was under the charge of a particular nurse who had to return more than +once to the family, and on each occasion was successful in breaking +the habit.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 64<a name="Page_64" id="Page_64"></a></span></p> + +<h3>CHAPTER IV</h3> + +<h3>WANT OF SLEEP</h3> + +<p> </p> +<p>So far, almost all that has been written—and there has been a great +deal of unavoidable repetition—has been devoted to an attempt to +determine the causes which lead the child to refuse food and the +methods which we adopt to prevent or overcome the difficulty. Other +neuroses may be studied in less detail, because they depend for their +existence upon the same causes. For example, the habit of refusing +sleep, which is as common and almost as distressing as the habit of +refusing food, depends both upon a perversion of suggestion and upon +the phenomenon that we have called negativism.</p> + +<p>If struggling and crying has occurred upon a series of nights, the +child comes to associate his bed not with sleep but with tears. If a +mother values her peace of mind, if she would spare herself the +discomfort of hearing her child sob himself nightly into uneasy sleep, +she must be wary how this all-important event of going to bed is +approached. With a nervous and restless child the preliminaries of +preparing for bed must be managed carefully and tactfully. The hour +before bedtime is almost +<span class="pagenum">Page 65<a name="Page_65" id="Page_65"></a></span> +universally the most interesting of the +whole day for the child. Then the baby, with his best frock on, and +books and toys, is the centre of interest in the drawing-room, till +the clock strikes and the nurse appears at the door. Suddenly it is +all over, and inexorable routine sends him off to bed. The good nurse +will give the child a little time to recover from the shock of her +arrival, and will not hurry him. She knows that his little mind is +slow to act, and that he must be led gradually to face a new prospect. +If she hurries him, catching him up in her arms from the midst of his +unfinished pursuits, resistance and tears are almost sure to follow, +and the difficult task of the day—the putting to bed—has made the +worst possible start. When this has happened on one or two successive +evenings, the habit of resistance to going to bed becomes fixed, and, +like all bad habits, is difficult to break. A nurse who has a way with +children will arouse his interest in a new pursuit, in which he can +play the chief part, the putting away of his picture books and toys. +If he is too small to carry his own chair or table to its allotted +place in the room, at least he can show his learning by pointing out +the spot. In the waving of good-byes he is expert and takes a +legitimate pride, and upstairs he has learnt that there are new +delights. He himself can turn on the taps in the bathroom, and he can +set every article in the proper place ready for use. All children love +their bath, and if interest and good temper has been so far preserved, +without a break, it will be ill-fortune if even the drying process is +not carried off <span class="pagenum">Page 66<a name="Page_66" id="Page_66"></a></span> +without a hitch. Afterwards, for a little, nervous +babies, whose brains still teem with all the excitements of the day, +are best left to sit for a few moments by the nursery fire, while the +nurse puts all the garments one by one to bed. Each as it goes to rest +will be greeted by him with cheerful farewells; and so does the force +of suggestion act, till the central figure himself plays his part in +the scene, of which he feels himself the controller and director, and +climbs to bed. But if there has been a hitch anywhere, if the bugbear +of negativism has appeared, if he has been scolded or coaxed or +repressed too much and there have been tears and struggles, then going +to bed is a poor preparation for instant and quiet sleep.</p> + +<p>With excitable, highly-strung children, the best laid plans and the +most tactful nurse will not always succeed, and to place him in his +cot is to provoke a storm of angry refusal and resistance. There are +mothers who believe that the best way is then to turn out the light +and leave the child to cry himself to sleep. This is a point on which +no one can lay down rules which are applicable for all children. It +may sometimes succeed, and the child may reason correctly and in the +way we wish him to reason, deciding that the game is not worth the +candle and so give it up. But with nervous, highly-strung children I +doubt if this Spartan conduct is commonly successful. Often if the +attempt is made, the troubled mother, listening to all these +heart-breaking sobs, can bear it no longer, and goes back to the side +of the cot to soothe and persuade +<span class="pagenum">Page 67<a name="Page_67" id="Page_67"></a></span> +him. Then certainly the longer she +has restrained her natural inclination, the longer the child has +sobbed himself into a pitiful little ball of perspiration and tears, +the more difficult will be her task in quieting him, the stronger will +be the impression formed on the child's mind, and the greater will be +the suggestion which will act under the same circumstances to-morrow. +Children who fall a prey to this uncontrolled crying, cry on because +they cannot stop when they have begun. They do not then cry purposely +or with a fixed intention, desiring to attain some object. They cry +because their minds are not at rest, but are irritated and overwrought +by the happenings of the day. We decided that it was useless to +attempt by exhortations at meal-times to induce a nervous child to eat +who habitually refuses food, and that we can only cure the condition +by eliminating from his daily life the elements of repression and +opposition which provoke the counter-opposition. And we must seek the +same solution in this other difficulty of the refusal of sleep. It is +useless to attempt to treat the symptom of refusal of sleep and to +leave the cause of that symptom still constantly in action.</p> + +<p>If, in spite of our care to avoid unrest and irritation of the child's +brain, sleep is refused, as may often happen, it is, as a rule, wise +to cut short the crying if we can, before a vicious circle has been +formed and the unrest has been intensified by the emotional storm. It +is useless with little children to urge them to go to sleep or to +coax. It is not usually wise to leave the child for a little and then +<span class="pagenum">Page 68<a name="Page_68" id="Page_68"></a></span> +to return. Each time the child is left, each time the mother or nurse +returns, the crying bursts forth again with renewed force and vigour. +It is at least one good plan with a little child to turn the light +out, and, treating the whole incident in the most matter-of-fact way +possible, lightly to stroke his head or pat his back rhythmically +without speaking. With older children, if the crying is more +purposeful and less emotional, the mother may busy herself for a +little with some task in the room, ostentatiously neglecting the storm +and making no reference to it. If she speaks to the child at all she +should do so in a matter-of-fact way, referring lightly to other +matters. If only she can convince him that his conduct is a matter of +indifference to her, the victory is won. It is because the child knows +so well that his mother does care that he so often has the upper hand. +It is not difficult to distinguish between a true emotional storm and +the tyrannous cry of a wilful child who demands his own way.</p> + +<p>Light and broken sleep is a common accompaniment of a too excitable +and overstimulated brain. The placid child, who eats well, plays +quietly, and does not cry more than is usual, as a rule sleeps so +soundly that no ordinary sounds, such as conversation carried on in +quiet tones in his neighbourhood, have the power to waken him. When he +wakes, he does so gradually, perhaps yawning and stretching himself. +The nervous child may move at the slightest sound, or with a sudden +start or cry is wide awake at once. A hard mattress should be +<span class="pagenum">Page 69<a name="Page_69" id="Page_69"></a></span> +chosen without a bolster, and with only a low pillow. Flannel pyjamas, which +cannot be thrown off in the restless movements of the child, should be +worn. The temperature of the room should be cool, and the air from the +open window should circulate freely, while draughts may be kept from +striking on the child by a screen. All the sensations of the nervous +child are abnormally acute. Thus, for example, an itching eruption, or +tight clothing, will produce an altogether disproportionate reaction, +and may result in a frenzy of opposition. Especially such a child is +sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool +rooms and warm but light and porous clothing are essential. An +electric torch, which can be flashed on the child for an instant, will +assist the mother or nurse to make sure that the child has not thrown +off all the bedclothing.</p> + +<p>Sometimes want of sleep is accounted for by a real want of physical +exercise. Town children especially are apt to suffer from their +limited opportunities of running freely in the open. It is often +considered enough that the child seated in his perambulator should +take the air for three or four hours daily, while much of his time +indoors as well is devoted to sitting. It is necessary for his proper +development that he should have opportunities of daily exercise in the +open. If for any reason this is not always practicable, a large room, +as free as possible from furniture, should be chosen, with windows +thrown wide open, in which the child may romp until he is tired.</p> + +<p><span class="pagenum">Page 70<a name="Page_70" id="Page_70"></a></span> +It is rare for children of two or of three years of age, whose case +we are now considering, to be troubled by bad dreams, nightmares, or +night-terrors. If these should occur, obstructed breathing due to +adenoid vegetations is sometimes at work as a contributory cause.</p> + +<p>Finally, we should always remember that refusal of sleep is, for the +most part, caused and kept up by harmful suggestions derived from +mother and nurse, who allow the child to perceive their distress and +agitation, who speak before the child of his habitual wakefulness, who +unwittingly focus his attention on the difficulty. It is cured in the +moment that the suggestion in the child's mind is reversed, in the +moment when he comes to regard it as characteristic of himself not to +make a fuss about going to bed, but to sleep with extraordinary +readiness and soundness. Let every one join together to produce this +effect. Let the suggestion act strongly on his mind that all these +troubles of sleeplessness are diminishing, that night after night sees +an improvement, and soon his reputation as a good sleeper will be +established, and, as always with children, it will be rigidly adhered +to.</p> + +<p>In assisting to break the habit of sleeplessness, and in the process +of altering the character of the suggestions which act on the child's +mind, we can be of the greatest assistance to the mother by +prescribing a suitable hypnotic. As to whether it is right in insomnia +in childhood to prescribe depressant drugs is a question on which very +various opinions are held. That it is wrong and +<span class="pagenum">Page 71<a name="Page_71" id="Page_71"></a></span> +probably ineffective to trust entirely to the drugs is certainly true, but as a +temporary measure, to break the faulty suggestion and the bad habit, their use +is both legitimate and successful. The dose required in children +relatively to the adult is much smaller. In grown people, some +specific distress of mind, whether real or imaginary, may suffice to +resist very large doses of hypnotic. In children it is rare to find +the same resistance, and comparatively small doses have a very +constant effect. With deeper and more refreshing sleep, the conduct of +the child during the day almost always changes for the better. A sound +sleep, for a few nights in succession, will produce apparently quite a +remarkable change in the whole disposition of the child. When good +temper and interest take the place of fretfulness and restlessness, we +may confidently expect that the symptom of sleeplessness will begin to +abate. Sleeplessness by night and fretfulness by day form a vicious +circle, and attempts must be made to break it at all points.</p> + +<p>Chloral occupies the first place as a hypnotic for young children. In +combination with bromide its effects are wonderfully constant and +certain. Two grains of chloral hydrate and two grains of potassium +bromide with ten minims of syrup of orange, given just before bedtime, +will bring sound sleep to a child of a year old. At three years the +dose may be twice as great, and three times at six years. It is seldom +that other means are required. Aspirin for children seems relatively +without effect. For children who are both sleepless and feverish, +<span class="pagenum">Page 72<a name="Page_72" id="Page_72"></a></span> +a grain of Dover's powder, and a grain of antipyrin, for each year of +the child's age up to three, is very helpful. Lastly, if chloral and +bromide cannot break the insomnia, and the condition of the child is +becoming distressing, we can almost always succeed if we combine the +prescription with an ordinary hot pack for twenty minutes.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 73<a name="Page_73" id="Page_73"></a></span></p> + +<h3>CHAPTER V</h3> + +<h3>SOME OTHER SIGNS OF NERVOUSNESS</h3> + +<p class="subhead">Habit Spasm</p> + +<p>Next to refusal of food and refusal of sleep perhaps the most frequent +manifestation of nervous unrest is provided by the group of symptoms +which we may call, with a certain latitude of expression, Habit +Spasms. By a habit spasm is meant the constant repetition of an action +which was originally designed to produce some one definite result, but +which has become involuntary, habitual, and separated from its +original meaning. The nervous cough forms a good example of a habit +spasm. A cough may lose its purpose and persist only as a bad habit, +especially in moments of nervousness, as in talking to strangers, in +entering a room, or at the moment of saying "How do you do" or +"Good-bye." Twitching the mouth, swallowing, elongating the upper lip, +biting the lips, wrinkling the forehead so strongly that the whole +scalp may be put into movement, and blepharospasm are all common +tricks of little children which may become habitual and uncontrolled. +In worse cases there may be constant jerking movements of the head, +nodding movements, or even bowing salaam-like movements. In mild +<span class="pagenum">Page 74<a name="Page_74" id="Page_74"></a></span> +cases we may note hardly more than a restless movement of mouth or +forehead, or constant plucking or writhing of the fingers whenever the +child's attention is aroused, when he is spoken to, or when he himself +speaks. In nervous children these movements, which should properly be +confined to moments of real emotional stress, become habitual, and are +displayed apart from the excitement of particular emotions. Whatever +their intensity, habitual and involuntary movements of this nature +should not be overlooked, and should be regarded as evidence of mental +unrest. They do not commonly appear during the first or second years +of the child's life. They are more frequent after the age of five, but +they may begin to be marked as early as the third year. With refusal +of food and refusal of sleep they form the three common neuroses of +early childhood.</p> + +<p>Two of the three qualities which we have mentioned as characteristic +of the child's mind are concerned in the causation of habit spasm. In +the early stages the movement is sometimes due to imitation, but the +susceptibility of the child to suggestion plays the chief part in +determining its persistence. It is an interesting speculation how far +tricks of gesture, attitude, or gait are inherited and how far they +are acquired by imitation. A child by some characteristic gesture may +strikingly call to mind a parent who died in his infancy. A whole +family may show a peculiarity of gait which is at once recognisable. +It is told of the son of a famous man, who shared with his father the distinctive +<span class="pagenum">Page 75<a name="Page_75" id="Page_75"></a></span> +family gait, that when a boy his ears were once boxed by +an old gentleman who chanced to observe him hurrying to overtake his +parent, and who resented what he took to be an act of impertinent +caricature. In the reproduction by the child of the habitual actions +of his parents, heredity is largely concerned, but imitation too plays +its part. In habit spasm the force of imitation is clearly seen. A +child who has developed a habit spasm of one sort or another will +readily serve as a model to other children. The malady will sometimes +spread through a school almost with the force of a contagious +disorder. A child affected in this way may prove an unwelcome guest. +The little visitor with a trick of contorting his mouth and grimacing +is apt to leave his small host an expert in faithfully reproducing the +action. A cough that is genuine enough in one member of the family may +produce a crop of counterfeits in brothers and sisters.</p> + +<p>The force of suggestion acting upon the child's mind can clearly be +traced. Once his attention is focused upon the particular movement by +unwise emphasis on the part of the parents, he loses the power to +control its occurrence. This trio of common neuroses—refusal of food, +refusal of sleep, and habitual involuntary movement—grows only in an +atmosphere of unrest and apprehension. Parents and nurses anxiously +watch their development. They are distressed beyond measure to note +their steady growth in spite of every attempt which they make to +control or forbid them. And of all this unrest and unhappiness the +child is acutely conscious. +<span class="pagenum">Page 76<a name="Page_76" id="Page_76"></a></span> +The whole household may become obsessed +with the misfortune which has befallen it, and the mother, losing all +sense of proportion, feels that she cannot regain her peace of mind +until it has been overcome. The child is in need of mental and moral +support from those around him, and all that he finds is an openly +expressed apprehension and sense of impotence. Even grown-up people, +when their nerves are on edge, are apt to be obsessed by +uncontrollable impulses or by vague and nameless apprehensions, and +surely all have learnt the support they gain from contact and +conversation with some one strong and sane, who treats their worries +in such a matter-of-fact way that immediately they lose their power +and become of no account. The child with habit spasm cannot control +these movements. The more he is reproved or entreated, the less able +does he find himself to hold them in check. He does not wish them to +continue. He has lost control of what he once controlled, and the +realisation of this is not pleasant, and may be alarming to him. Yet +when unconsciously he looks to his mother for support, he finds in her +open dismay that which serves only to increase his uneasiness. She +must subdue her own feelings and give the child strength. If she +treats the whole thing in a matter-of-fact way, as a temporary +disturbance which is of no importance in itself, and only has meaning +because it implies that the brain has been over-stimulated, she will +no longer exercise a prejudicial effect on the child. If the bad habit +is taken as a matter of course, if too much is not made +<span class="pagenum">Page 77<a name="Page_77" id="Page_77"></a></span> +of it, if the child is encouraged to think that nobody cares much about it at all, +then recovery will soon take place. It goes without saying that habit +spasms and tics of all sorts are made worse by excessive emotional +display and by nervous fatigue. On the other hand, if the child +becomes absorbed in some interesting occupation, the movements will +disappear for the time being.</p> + + +<p class="subhead">Air Swallowing, Thigh Rubbing, Thumb Sucking</p> + +<p>At a somewhat earlier age than that in which habit spasms become +common, and before bed wetting appears as a formidable difficulty, we +meet with another group of habitual actions which yet retain their +voluntary character. Among such habitual actions are thumb sucking, +thigh rubbing, and air swallowing. If the child is old enough to +express himself on the subject, he will explain that these actions are +performed because of the satisfaction derived from them, because it is +"comfy" and "nice." Even if the child is too small to speak, the +expression is that of beatitude and content. These actions are not +confined to nervous children, and their occasional practice need not +be taken to imply that there is any strong element of nervous +overstrain. It is only when the action is repeated with great +frequency and persistence, and when signs of irritation ensue if +gratification is not obtained, that we are justified in classing it +among the symptoms of mental unrest.</p> + +<p><span class="pagenum">Page 78<a name="Page_78" id="Page_78"></a></span> +The second of these actions, thigh rubbing, is found for the most +part in little girls, and inasmuch as it consists of a stimulation of +the sexual organs sometimes causes much distress to the parents. It is +in reality a habit of small importance unless exercised with very +great frequency. It is, of course, not associated in the child's mind +with any sexual ideas, and is of precisely the same significance as +the other two actions of the same class. Children who can speak will +refer to it openly without any sense of shame. As a rule the action is +performed in a half-dream state, that condition between sleeping and +waking which is found when the child is lying in the morning in her +cot or in her perambulator after the midday nap. The child's attention +should not be focused on the symptom. She should lie on a hard +mattress, and when she wakes in the morning she should either leave +her cot at once or she should be roused into complete wakefulness by +encouraging her to play with her toys. Little children should be +taught to sleep with their hands folded and placed beside the cheek. +If the movement occurs on going to sleep, it is best left alone and +completely neglected. As a rule each child has his or her own +favourite action of this class, and they are seldom combined in the +same child. If thigh rubbing is very constant and obstinate and does +not yield to the measures suggested, it may even sometimes be a +successful manoeuvre to substitute the thumb-sucking habit in the +expectation that this less distressing habit may eject the other more +objectionable action. +<span class="pagenum">Page 79<a name="Page_79" id="Page_79"></a></span> +As a rule, however, a wise neglect and careful +watching during the drowsy condition that follows sleep in a warm bed +will succeed in stopping the practice of thigh rubbing before the end +of the second or third year. Apparatus designed to restrain movement +of the child's legs or blistering the opposed surfaces of the thighs +are both of no effect. They have indeed the positive disadvantage that +they focus the child's attention on the practice. The habit ceases +only when the child has forgotten all about it, and these devices +serve only to keep it in remembrance. The same may be said of any +system of punishments. Further, we cannot always have the child under +observation, and at some time or other opportunity will be found for +gratification. Of older children, in whom self-control and a sense of +honour can be cultivated, I am not here speaking.</p> + +<p>Air swallowing is less common than thigh rubbing, but belongs to the +same group of actions and takes place in the same drowsy condition. +The child will rapidly gulp down air which distends the stomach, and +is then regurgitated with a loud sound. Thumb sucking seldom +distresses the mother to the same extent, and the proper attitude of +tolerance is adopted towards it. If much is made of it, it is +astonishing how persistent the habit may become, surviving all +attempts to forbid it, to break it by rewards or punishments, or to +render it distasteful by the application of a variety of ill-tasting +substances smeared on the offending digit. +<span class="pagenum">Page 80<a name="Page_80" id="Page_80"></a></span></p> + +<p class="subhead">Pica and Dirt Eating</p> + +<p>Certain other bad habits will become ingrained if attention is called +to them, because of that curious spirit of opposition which +characterises little children, and because of their susceptibility to +suggestion. Some children will constantly pluck out hairs and eat +them, or will devour particles of fluff drawn from the blankets. +Others will seize every opportunity to eat unpleasant things, such as +earth, sand, mud, or dirt of any sort. All tricks of this sort are +best neglected and treated by attracting the child's attention to +other things. In adult life they are associated with serious mental +disturbance, in early childhood they are of little account, or at most +suggest a certain nervousness which may be due to nervous irritation +from faults of management which we must strive to correct.</p> + + +<p class="subhead">Constipation</p> + +<p>As has been already mentioned, much of the common constipation of the +nursery is due to neurosis. The excessive concentration of the nurse's +thoughts on this daily question communicates itself to the child. The +difficulty is emphasised, and an attempt is made to substitute will +power for forces of suggestion which are at once inhibited by +concentration of the mind upon the process. Here also, just as in the +refusal of food, a further stage of "negativism," that is, of active +resistance with crying and struggling, is reached, so that complaint +<span class="pagenum">Page 81<a name="Page_81" id="Page_81"></a></span> +may be made by the mother that defæcation is painful. The same +negativism may be shown in micturition, and mothers will give +distressing accounts of the suffering of the child during the passing +of water.</p> + + +<p class="subhead">Breath-Holding and Laryngismus Stridulus</p> + +<p>In some children, in the first two years of life, we find a definite +and measurable increase in the irritability and conductivity of the +peripheral nerves. The strength of current necessary to produce by +direct stimulation of the nerve a minimal twitch of the corresponding +muscle may be many times less than the normal. Of this heightened +irritability of the nervous system, to which the name "spasmophilia" +has been given in America and on the Continent, the most striking +symptom is a liability alike to tetany or carpo-pedal spasm, to +generalised convulsions, and to laryngismus stridulus. In addition, in +most cases it is generally possible to demonstrate the presence of +Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a +visible twitch of the facial musculature, especially of the +orbicularis palpebrarum or of the orbicularis oris, in response to a +gentle tap administered over the facial nerve in front of the ear. +Trousseau's sign is the production of tetany by applying firm and +prolonged pressure to the brachial nerve in the upper arm. The +ætiology of spasmophilia is still a matter for dispute, but the +evidence which we possess is in favour of the view that we +<span class="pagenum">Page 82<a name="Page_82" id="Page_82"></a></span> +have here to deal with a disturbance of calcium metabolism. The calcium content +both of the blood and of the central nervous system has been shown to +be much lowered. It is in keeping with this that clinically we note +how frequently spasmophilia and rickets occur in the same child. In +some families the condition recurs through many generations.</p> + +<p>For our present purpose—the examination of some common neuroses of +nursery life—it would be out of place to enter into a detailed +consideration of this disorder of spasmophilia as a whole. The symptom +of laryngismus stridulus—the so-called breath-holding—alone need +concern us, and that for a special reason. The spasm of the glottis is +produced under the influence of any strong emotion—in anger, for +example, or in fear, in excitement or in crying for any reason. To +control or prevent it we must direct attention not only to the +condition of spasmophilia, but also to the management of the children +who are always excitable and emotional. In these children every burst +of crying, however produced, whether by a fall, by a fright, by the +entrance of a stranger, or by a visit to a doctor, is apt to be +ushered in by a long period of apnœa, due to spasm of the glottis +and of the diaphragm. The first few expirations are not followed by +any inspiration. For several seconds the silence may be complete, +while the child steadily becomes more and more cyanosed, or the body +may be shaken by incomplete expiratory movements and strangled cries +which are suppressed because the chest is already in a position of +almost complete expiration. +<span class="pagenum">Page 83<a name="Page_83" id="Page_83"></a></span> +In the worst cases, when the apnœa +lasts a very long time, there may be convulsive twitching of the +muscles of the face, or the attack may even terminate in general +convulsions. Very occasionally the spasm is actually fatal. In all +fatal cases which have come to my notice the child at the moment of +death had been alone in the room. I have met with no fatal case where +the baby could be picked up and assisted. As a rule, therefore, the +cause and mode of death must be conjectural, but when an infant is +found dead in its cot unexpectedly, it would seem likely that it has +waked from sleep with a sudden start, become excited, and, about to +cry, has been seized by the fatal spasm. In two instances reported to +me a cat had been found in the room with the dead child, and it was +suggested that the animal had lain upon the child's face. Both these +children, however, were vigorous and capable of powerful movements of +resistance. I think it more likely that the cat may have awakened them +in fright, and that the emotional excitement, giving rise to the +spasm, was the cause of the suffocation. That the apnœa in these +extremely rare instances should end fatally produces a difficult +position for the doctor. It need hardly be said that the seizures are +alarming to the parents. For the sake of great accuracy in the +statement of our prognosis are we to add a hundred times to the +mother's alarm by stating the possibility of death? In each case we +must use our own judgment. I believe that in a child over a year old +the risk is almost negligible.</p> + +<p><span class="pagenum">Page 84<a name="Page_84" id="Page_84"></a></span> +Fortunately in all save the rarest possible instances the apnœa +yields and a deep inspiratory movement follows. As the air rushes past +the glottis, which is still partially closed, a sound recalling the +whoop of pertussis is heard. Often this recurs throughout all the +burst of crying which follows, and each inspiration is accompanied by +a shrill stridulous sound. With the re-establishment of respiration +the cyanosis rapidly fades, to be succeeded in some cases by pallor +and perspiration.</p> + +<p>It need hardly be said that we should do all in our power to prevent +these alarming and distressing attacks. Each seizure predisposes to a +repetition. In some children we notice that months and even years +after an attack of whooping-cough, a slight bronchial catarrh may be +sufficient to bring back the characteristic cough. In laryngismus in +the same way we may suppose that the reflex path is made easy and the +resistance lowered by constant use. Fortunately the spasms are not +usually difficult to control. Calcium bromide, in doses of from two to +four grains, according to age, three times daily, is generally +successful with or without the addition of chloral hydrate in small +doses. At the same time we must endeavour in every way possible to +keep the child calm, by paying close attention to nursery management. +The child with spasmophilia is as a rule excitable and easily upset, +and although calcium bromide is a drug which offers powerful aid it is +not able to achieve its effect unless we are able at the same time to +guarantee a reasonable immunity from emotional upsets. It is for this +<span class="pagenum">Page 85<a name="Page_85" id="Page_85"></a></span> +reason that I have included some description of laryngismus, although +its origin is undoubtedly very different from that of the other +disorders of conduct which we have examined.</p> + + +<p class="subhead">Migraine and Cyclic Vomiting</p> + +<p>The ætiology of cyclic or periodic vomiting in childhood is not yet +completely understood. We do not know how far it is dependent upon +disturbance of the liver, and it is still disputed whether the +acidosis which accompanies it is the cause or the result of the +profuse vomiting. Into these difficult questions we need not at the +moment enter. It is enough in the present connection to recognise that +the great majority of children who suffer from cyclic vomiting are +sensitive, excitable, and nervous, and that every one is agreed that +the nervous system is intimately concerned in its causation.</p> + +<p>A close association between cyclic vomiting in children and that form +of periodic headache known as migraine has often been observed. It is +sometimes found that one or both parents of a child with cyclic +vomiting suffer habitually from migraine. In a few instances the one +condition has been observed to be gradually replaced by the other, the +child with cyclic vomiting becoming in adult life a sufferer from +migraine. There is indeed much which is common to the two conditions. +The periodic nature of the seizure, often following a time when the +general health and vigour appear to have been at their optimum, the +extreme prostration, <span class="pagenum">Page 86<a name="Page_86" id="Page_86"></a></span> +and the comparatively sudden recovery are found +in both. In the cyclic vomiting of children, it is true, little +complaint is made of headache, the visual aura is absent, and the +vomiting is invariably the most prominent symptom.</p> + +<p>Cyclic vomiting seldom occurs before the fourth year. It is +characterised by sudden profuse and persistent vomiting and by very +great prostration. All food, it may be even water, is promptly +rejected. The vomited matter is generally stained with bile; +occasionally the violence of the vomiting causes hæmatemesis. In many +cases the temperature is raised; sometimes it may be as high as 103° +F. The duration of an attack varies. In most cases it does not last +longer than forty-eight hours. On the other hand, attacks lasting as +long as a week are by no means unknown. Within a short time of the +onset the urine may be found to contain acetone bodies, the breath may +smell distinctly of acetone, and the child may become torpid and +drowsy or agitated and restless. At times there may be exaggerated and +deepened respiratory movements—the so-called air hunger. In many +cases, however, otherwise characteristic, these more severe +manifestations are absent or but little apparent. Recovery is usually +rapid and complete. The child asks for food, which is retained. A +fatal ending is very rare, though not unknown. The frequency of +attacks is very various. Sometimes months or even years may elapse +between successive seizures; in other cases a fortnightly or monthly +rhythm establishes itself.</p> + +<p><span class="pagenum">Page 87<a name="Page_87" id="Page_87"></a></span> +It is clear that both the frequency and the severity of the attacks +are much influenced by the general state of the child's health. Like +migraine, cyclic vomiting appears to be a symptom of nervous +exhaustion. It affects, for the most part, children who are +intellectually alert, impressionable, and forward for their age, and +who, when well, throw themselves into work or play with a great +expenditure of nervous energy. Often their physical development is +unsatisfactory, and we must set ourselves to correct this as the first +step in prevention. It is highly important that children suffering in +this way should have free opportunities for exercise in the open +country, and that all the excretory organs—the skin, kidneys, and +bowels—should be acting freely and efficiently. The child should live +a life of ordered routine. Sleep should be sound and sufficient in +amount. The diet must not exceed the strict physiological needs. Many +of these children appear to have a lowered tolerance for fats of all +sorts, and it may be necessary to limit strictly the consumption of +milk, cream, butter, and so forth. A daily administration of a small +dose of alkali by the mouth is credited with preventing attacks. In +the present connection, however, we shall not do wrong to emphasise +the part played by the nervous system in the production of the +attacks. In all cases of cyclic vomiting it should be our endeavour to +recognise and remove the elements in the daily life of the child which +are proving too exhausting. +<span class="pagenum">Page 88<a name="Page_88" id="Page_88"></a></span></p> + +<p class="subhead">Unexplained Pyrexia</p> + +<p>In nervous children we sometimes meet with inexplicable rises of +temperature. The pyrexia may have the same periodic character as that +just noted in cases of cyclic vomiting. At intervals of three, four, +or five weeks there may be a rise of temperature to 103° F., or even +higher, which may last for two or three days before subsiding. In +other cases the chart shows a slight persistent rise over many weeks +or months. That in nervous children the temperature may be very +considerably elevated without our being able to detect much that is +amiss does not of course make it any the less necessary to be careful +to exclude organic disease. Pyelitis, tuberculosis, and latent otitis +media occur with nervous children as with others and must not be +overlooked. If, however, organic disease can be excluded, and if the +pyrexia is the only circumstance which prevents the decision that the +child is well and should be treated as well, then the thermometer may +be overruled and the pyrexia neglected.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 89<a name="Page_89" id="Page_89"></a></span></p> + +<h3>CHAPTER VI</h3> + +<h3>ENURESIS</h3> +<p> </p> + +<p>I have dealt in previous chapters with certain common disorders of +conduct in childhood, which show clearly their origin in the +apprehensions of the grown-up people who have charge of the children, +and in the unwise suggestions which they convey to them. The same +forces are at work in the production of enuresis, or bed wetting, +although the matter is here often complicated by the development later +on of a sense of shame and unhappiness in the child. There comes a +time when the child passionately desires to regain control and is +miserable about her failure, until the concentration of her thoughts +on the subject becomes a veritable obsession. Every night she goes to +bed with this only in her mind. Every night she falls asleep, +miserably aware that she will wake to find the bed wetted. The +suggestion impressed in the first place on the mind of the tiny child +by injudicious management has become fixed by the growing sense of +shame and the complete loss of self-confidence.</p> + +<p>It is usually taught that a great variety of causes is concerned in +producing enuresis. It is said to be due to a partial asphyxia during +sleep from +<span class="pagenum">Page 90<a name="Page_90" id="Page_90"></a></span> +adenoid vegetation. It is said to be caused by phimosis, +and to be cured by circumcision. It is said that the urine is often +too acid and so irritating that the bladder refuses to retain it for +the usual length of time. It is said that enuresis may be due to a +deficiency of the thyroid secretion, and that it can be cured by +thyroid extract. Such a number of rival causes may make us hesitate to +accept the claims of any one of them. Certainly I have not been able +to satisfy myself that any one of these conditions exercises any +influence at all or is commonly present in cases of enuresis. I think +that if we examine a large number of cases of bed wetting in children +we can come to no other conclusion than that the cause of the trouble +is due to just such a pervasion of suggestion as we have been +considering above.</p> + +<p>There are certain points in the behaviour of a child with enuresis +which seem to point to this conclusion.</p> + +<p><i>(a)</i> In the first place, the trouble is seldom serious or very well +developed in early childhood, and the reason for this, I take it, is +that an occasional lapse in a child of perhaps two or three years of +age is usually treated lightly and in the proper spirit of tolerance. +It is only with children a little older that nurses and parents become +distressed and begin unwittingly by urging the child to present the +suggestion to her mind, that the bed may or will be wetted. Hence the +usual history is that control was partially acquired in the second +year, but that, instead of later becoming complete, relapses +<span class="pagenum">Page 91<a name="Page_91" id="Page_91"></a></span> +began to be more frequent, and that since that time all that can be done seems +only to make matters worse.</p> + +<p><i>(b)</i> In the second place, the influence of suggestion is shown by the +behaviour of the child when removed to a hospital for observation. It +is the invariable experience that the enuresis then promptly stops. In +hospital the attitude of those around the child is entirely different. +She has the comfortable and consoling feeling that in wetting the bed +she is doing exactly what is expected of her. There is even a feeling +that otherwise she is showing herself to be something of a fraud, and +that she has then been admitted to the hospital on false pretences. +Hence, perhaps for the first time in many years, the child is free +from the obsession, and the bed is not wetted.</p> + +<p><i>(c)</i> In the third place, it is easy to recognise in the history of +many of the cases, the ill-effects of circumstances which add new +force to the fear of failure or shake the confidence in the control +which had been regained. Thus a boy, an only child, who had suffered +from enuresis till his seventh year, had regained complete control +till his eleventh year, when he went to school. In his dormitory at +school was a boy who had enuresis, and who was being fined and +punished by the schoolmaster. The enuresis at once reappeared and +continued unchecked so long as he was at school. As might be expected, +school life is very inimical to cure, unless the trouble can be kept +from the knowledge of the other boys. Anything which directly +<span class="pagenum">Page 92<a name="Page_92" id="Page_92"></a></span> +increases the nervousness of the child—an illness, for example, with +loss of weight and failure of nutrition, or some mental stress, such +as the approach of an examination—is apt to accentuate the enuresis.</p> + +<p><i>(d)</i> In the fourth place, the incontinence sometimes spreads to the +daytime, and the child is wet both by day and night. Further, in bad +cases it is not uncommon to find incontinence of fæces making its +appearance also. These extensions of the fault only take place when +the management continues to be very faulty, when the grown-up people +around them are more than usually distressed and pessimistic, and have +redoubled their expostulations and appeals.</p> + +<p>Now these peculiarities of enuresis seem to me only explicable if we +assume that the want of control is due to auto-suggestion, dependent +at the beginning on the unwise attitude adopted towards the fault by +the nurses and parents, and later kept up by the sense of shame and +the mental distress involved.</p> + +<p>The forms of treatment which have been recommended from time to time +are, as might be expected, very numerous.</p> + +<p><i>(a) Operative.</i>—(i) Removal of tonsils and adenoids, (ii) +Circumcision.</p> + +<p><i>(b) Manipulative.</i>—(i) Injection of saline solution under the skin +in the perineal and pubic regions, with object of lowering the +excitability of the bladder by counter-irritation. (ii) Gradual +distension of the bladder by hydrostatic pressure, (iii) Tilting the +foot of the bed so as to throw the +<span class="pagenum">Page 93<a name="Page_93" id="Page_93"></a></span> +urine to the fundus of the +bladder, in order to protect the sensitive trigone from irritation.</p> + +<p><i>(c) Educative.</i>—(i) Curtailing the fluid drunk. (ii) Waking the +child at intervals during the night by an alarm clock or otherwise. +(iii) Rewards and punishments.</p> + +<p><i>(d) Medicinal.</i>—(i) Belladonna. (ii) Thyroid extract.</p> + +<p><i>(e) By Suggestion.</i>—(i) By simple suggestion. (ii) By hypnotic +suggestion.</p> + +<p>I do not think that any single one of these various forms of treatment +outlined under the first four heads has any effect other than to aid +the suggestion of cure which we proffer in adopting it. Removal of +tonsils and adenoid vegetations might conceivably cure an enuresis +which is nocturnal, it cannot account for an incontinence which +spreads to the day. We might believe that to distend the bladder by +hydrostatic pressure was a cure for incontinence of urine, and that it +acted by removing the local cause,—the smallness and contraction of +the bladder,—were it not that the loss of control is so apt to spread +to the rectum as well. There is no evidence that the urine is +peculiarly irritating. Indeed, such evidence as we have goes to show +that, as in some other neuroses, the urine in enuresis is unduly +copious, and of very low specific gravity. Incidentally, we have in +this polyuria a further argument against the view recently advanced +that a small and contracted irritable bladder is the cause of +enuresis. We do, of course, meet with cases of irritable bladder often +enough, but the complaint is +<span class="pagenum">Page 94<a name="Page_94" id="Page_94"></a></span> +then not of incontinence, but always of +the discomfort of having to rise so frequently for micturition.</p> + +<p>To deprive the child of fluid, to wake her many times at night, to +tilt the foot of the bed, are devices which may help in the hands of +some one who is confident of his ability to cure the condition and can +communicate the confidence to the child. Carried out hopelessly and +pessimistically by a tired and exasperated mother, they are well +calculated to strengthen the hold which the obsession has on the +child, so that often we meet with a mother who rightly enough +maintains that the more she wakes the child, the oftener the bed is +wet, till she wonders where it all comes from.</p> + +<p>The treatment of enuresis to be successful must be conducted through +and by means of the grown-up persons who have the control of the +children. To stop the development of enuresis in early infancy we must +intervene to prevent the concentration of the child's mind on the +difficulty. During the time when control is ordinarily developed, in +the second and third year, judicious management of the child is +essential. The emphasis should be laid upon successes, not upon +failures. For every child his reputation will sway in the balance for +a time. He must be helped and encouraged to self-confidence, not +rendered diffident or self-conscious.</p> + +<p>If the case is well established before it comes under our notice, the +mother, the nurse, the schoolmaster, or whoever is responsible for the +child's management, must understand clearly the nature of the trouble. +The suggestion acting on the +<span class="pagenum">Page 95<a name="Page_95" id="Page_95"></a></span> +child's mind must be altered, and +self-confidence restored. The child must learn to see that the thing +is not so desperately tragic. He should be told that the trouble +always gets well, and that it only goes on now because he is worried +about it and keeps thinking of it. If the whole environment of the +child is bad, so that such a change of suggestion is not possible, and +if enuresis is but one of many symptoms of mental or moral +instability, it may be necessary to remove the child and place him +under the influence of some one else. Sometimes the prescription of a +rubber urinal, which the child can slip on at night, is directly +curative. A public school boy, who was about to be sent away from +school for this failing, fortified by the possession of this +apparatus, wrote six months later to say that he knew now that it must +be all worry that caused the trouble, because with the urinal in +position he had not once had the incontinence.</p> + +<p>In inveterate cases hypnotic suggestion is always, I think, +successful. It is obvious, however, that in many cases there are +objections to its use. Often enuresis is evidence that the child's +home environment has been at fault, and that his mental and moral +development has been retarded. It is the management which must be +modified or the home, if necessary, changed. Hypnotic suggestion will +make this one symptom disappear promptly enough, but it will rather +perpetuate than combat the cause—that undue susceptibility to +suggestion, which is characteristic alike of the little child and of +many older neuropathic persons.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 96<a name="Page_96" id="Page_96"></a></span></p> + + +<h3>CHAPTER VII</h3> + +<h3>TOYS, BOOKS, AND AMUSEMENTS</h3> +<p> </p> + +<p>Any one who has an opportunity of watching little children must have +observed that they are happiest and most contented when playing alone. +The education of the little child is carried on by means of games and +toys. Handling the various objects which we give him, imparting +movement to them, transferring them from hand to hand and from one +situation to another, he learns dexterity and precision of movement, +and in the process hand and brain grow in power. When at play, his +whole energies should be absorbed to the exclusion of everything else. +He will often be oblivious to everything that is going on around him, +intent only on the purpose of the moment. In order to permit this +fervour of self-education it is necessary that the child should be +accustomed to playing alone, and it is well, if only for convenience' +sake, that he should be accustomed to playing in a room by himself. +Something is wrong if the child cannot be left for a few moments +without breaking into tears or displaying bad temper. Engrossed in his +own tasks, he should be content to leave his nurse to move in and out +of the room without +<span class="pagenum">Page 97<a name="Page_97" id="Page_97"></a></span> +protest. If this fault has appeared and the child +cannot be left alone, our whole educational system is undermined, and +play will be profitless and over-exciting, because it demands the +constant participation of grown-up people. As a preliminary to all +improvement in the management of a nervous child, we must see to it +that he becomes accustomed to being alone. We must so arrange his +nursery that he can do no damage to himself. Scissors and matches must +not be left lying about, and a fireguard must be fixed in position so +that it cannot be disturbed. Then, disregarding his protests, the +nurse must leave him to himself, at first only for a moment or two, +re-entering the room in a matter-of-fact way without speaking to him, +and again leaving it. Soon he will learn that a temporary separation +does not mean that we have abandoned him for all time. Then the period +of absence can be gradually lengthened till all difficulty disappears. +Once his attention is removed from the grown-up people who mean so +much to him, his natural impulse to explore and experiment with his +playthings will show itself. Those toys are best which are neither +elaborate nor expensive. For a little child a small box containing a +miscellaneous collection of wooden or metal objects, none of them +small enough to be in danger of being swallowed, forms the material +for which his soul craves. Everything else in the room may be out of +his reach. A dozen times he will empty the box and then replace each +object in turn. He will arrange them in every possible combination, +and then sweep the whole away to start afresh.</p> + +<p><span class="pagenum">Page 98<a name="Page_98" id="Page_98"></a></span> +At eighteen months of age observation and imitative capacity will +have made more complex pursuits possible. As a rule the objects which +are most prized and which have most educative value are those which +lend themselves best to the actions with which alone the child is +familiar. Hence the supreme importance of the doll and the doll's +perambulator. The doll will be treated exactly as the child is treated +by the nurse. It will be washed, and dressed, and weighed, and put to +bed in faithful reproduction of what the child has daily experienced. +Dusting, and sweeping, and laying the table will be exactly copied. If +a child has no opportunity of being familiar with horses, if he has +not seen them fed, and watered, and groomed, and harnessed, he may not +find any great satisfaction in a toy horse, or pay much attention to +it, no matter how costly or realistic it may be.</p> + +<p>In the third year more precise tasks, such as stringing beads, +drawing, and painting, will play their part, while at the same time +the increased imaginative powers will give attraction to toy soldiers +or a toy tea-service. Playing at shop, robbers, and rafts are +developments of still later growth. In the child's games we recognise +the instinct of imitation—playing with dolls, sweeping and dusting, +playing at shop or visitors; the instinct of constructiveness—making +mud pies and sand castles, drawing or whittling a stick; and the +instinct of experiment—letting objects fall, rattling, hammering, +taking to pieces. All this activity must be encouraged, never unduly +repressed or destroyed. +<span class="pagenum">Page 99<a name="Page_99" id="Page_99"></a></span> +But whatever form it takes, the bulk of the +play must be carried on without the intervention of grown-up persons, +or it will lose its educative value and prove too exacting. If +grown-up people attempt to take part, the child will lose interest in +the play and turn his attention to them.</p> + +<p>Children differ very much in their attitude towards books. One child +quite early in the second year will be happy poring over picture +books, while another will seldom glance at the contents and finds +pleasure only in turning over the pages, opening and shutting them, +and carrying them from place to place. Such differences are natural +enough and foreshadow perhaps the permanent characteristics that +divide men and women, and produce in later life men of thought and men +of action, women who are Marthas and women who are Marys. +Nevertheless, we should bear in mind that there is danger in a +training that is too one sided, and that books and toys have both +their part to play in developing the powers of the child. All the +activities of the child should be used in as varied a way as possible. +The eye is but one doorway to knowledge and understanding, the ear is +another, the hand a third.</p> + +<p>From pictures an imaginative child will derive very strong +impressions, and mothers should be careful in their choice. It is +foolish to confuse the growth of æsthetic perceptions by presenting +children with books which depict children as grotesquely ugly beings +with goggle eyes and heads like rubber balls. Children love animals and +<span class="pagenum">Page 100<a name="Page_100" id="Page_100"></a></span> +endow them with all their own reasoning attributes, and in +stories of the home life of rabbits, and bears, and squirrels they +take a pure delight. Books of the "Struwwelpeter" type are less to be +recommended. The faults which they are intended to eradicate become +peculiarly attractive from much familiarity. A little boy of two and a +half who resolutely refused all food for some days was in the end +detected to be playing the part of that Augustus, once so chubby and +fat, who reduced himself to a skeleton, saying, "Take the nasty soup +away; I don't want any soup to-day." Tales of naughty children who +meet with a distressing fate may either frighten the child unduly, or +else produce in a child of inquiring mind the desire to brave his fate +and put the matter to the test. Pictures should not be terrifying or +horrible. Ogres devouring children are out of place as subjects for +pictures and may cause night-terrors.</p> + +<p>Children should be taught to be careful of books and toys. The +indestructible book, generally falsely so called, is often responsible +for the immediate dissolution of all others less protected which come +to hand. The sympathy which little children have with the sufferings +of all inanimate objects and their habit of endowing them with their +own sensations may be made of use in teaching them care and +gentleness. They are naturally prone to sympathise with the doll that +has been crushed or the book that has been torn. They will learn very +easily to be kind to a pet animal and to be solicitous for its +feelings, and the lesson so learnt will be applied to inanimate +objects as well.</p> + +<p><span class="pagenum">Page 101<a name="Page_101" id="Page_101"></a></span> +There is, however, another side to the question. It is true that if +the child is not to be over-stimulated upon the psychical side, we +must see to it that his play, for the most part, is not dependent upon +the participation of grown-up persons. In practice this excessive +stimulation is the common fault with which we meet. There are few +children in well-to-do homes, with loving mothers and devoted nurses, +who suffer from too little mothering and nursing. Too many show signs +of too much. To observe the opposite fault we must seek the infants +and children who for a long time are inmates of institutions, +orphanages, infirmaries, hospitals, and so forth. In such surroundings +the mental life of the child may languish. His physical wants are +cared for, but there the matter ends. In a rigid routine he is washed +and fed, but he may not be talked to or played with or stimulated in +any way. His day is spent passively lying in his cot, unnoticed and +unnoticing. I have seen a poor child of three years just released from +such a life, and after eighteen months returned to his mother, unable +to talk and almost unable to walk, crying pitifully at the novelty and +strangeness of the noisy life to which he had returned, worried by +contact with the other children, and without any desire or power to +occupy himself in the home. For an hour in the day mothers may devote +themselves wholeheartedly to the children, and if they set them +romping till they are tired out, so much the better. In the garden or +in an airy room with the windows open, a game with a ball or a toy +balloon, or a <span class="pagenum">Page 102<a name="Page_102" id="Page_102"></a></span> +game of hide-and-seek, will be all to the good, and the +children may climb and be rolled over and swung about to their heart's +content. With an only child, especially with a child whose home is in +town, and whose outings are limited to a sedate airing in the park, +such free play is especially necessary. It may help more than anything +else to quiet restless minds and tempers that are on edge all day long +from excessive repression.</p> + +<p>On the other hand, those forms of entertainment which are known as +"children's parties" are generally fruitful of ill results, at any +rate with nervous and highly-strung children. Sometimes they entail a +postponement of the usual bedtime, and nearly always they involve +over-heated and crowded rooms. Perverse custom has decreed that these +gatherings shall take place most commonly in the winter, when dark and +cold add nothing to the pleasure and a great deal to the risk of +infection which must always attend the crowding of susceptible +children together in a confined space with faulty ventilation. There +is clearly on the score of health much less objection to summer garden +parties for children, but these for some reason are less the vogue. As +a rule parties are not enjoyed by nervous children. There is intense +excitement in anticipation, and when at length the moment arrives, +there is apt to be disillusion. Either the excitement of the child may +pass all bounds and end in tears and so-called naughtiness, or the +unfamiliar surroundings may leave him distrait with a strange sense of +unreality and unhappiness. It is not +<span class="pagenum">Page 103<a name="Page_103" id="Page_103"></a></span> +always fair to blame the want of +wisdom in his hostess's choice of eatables, if the excited and +overstimulated child fails in the work of digestion and returns to the +nursery to suffer the reaction, with pains and much sickness.</p> + +<p>The same arguments may be urged against taking little children to the +theatre. The nerve strain is apt to be out of proportion to the +enjoyment gained. If children must go to theatres and parties, the +treat should be kept secret from them until the moment of its +realisation, in order that the period of mental excitement should be +contracted as much as possible, and grown-up people should be advised +to treat the whole expedition in a matter-of-fact sort of way that +does nothing to add to the excitement or increase the risk of +subsequent disillusion.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 104<a name="Page_104" id="Page_104"></a></span></p> +<h3>CHAPTER VIII</h3> + +<h3>NERVOUSNESS IN EARLY INFANCY</h3> +<p> </p> + +<p>We may now pass back to consider the nervous system of the child in +infancy. There, too, from the moment of birth there are clearly-marked +differences between individuals. The newborn baby has a personality of +his own, and mothers will note with astonishment and delight how +strongly marked variations in conduct and behaviour may be from the +first. One baby is pleased and contented, another is fidgety, +restless, and enterprising. At birth the baby wakes from his long +sleep to find his environment completely changed. Within the uterus he +lies in unconsciousness because no ordinary stimulus from the outer +world can reach him to exert its effect. He lies immersed in fluid, +which, obeying the laws of physics, exercises a pressure which is +uniformly distributed over all points of his body. No sound reaches +him, and no light. After birth all this is suddenly changed. The sense +of new points of pressure breaks in upon his consciousness. Cold air +strikes upon his skin. Loud sounds and bright lights evoke a +characteristic response. A placid child who inherits a relatively +obtuse nervous organisation will be but little upset by this sudden +<span class="pagenum">Page 105<a name="Page_105" id="Page_105"></a></span> +and radical change in the nature of his environment. His brain is +readily but healthily tired by the new sensations which stream in from +all sides, and he falls straight away into a sleep from which he +rouses himself at intervals only under the impulse of the new +sensation of hunger.</p> + +<p>Babies of nervous inheritance, on the other hand, will show clearly by +the violence of the response provoked that their nervous system is +easily stimulated and exhausted. They will wriggle and squirm for +hours together, emitting the same constant reflex cry. The whole body +will start convulsively at a sudden touch or a loud sound which would +evoke no response from a more stolid infant. The sleeplessness and +crying exhaust the baby, rendering the nervous system more and more +irritable, while the sensation of hunger which is delayed in other +children by twelve hours or more of deep sleep appears early and is of +extreme intensity. We must see to it that sense stimuli are reduced to +the lowest possible level. True, we cannot again restore the child to +a bath of warm fluid, of the same temperature as his body, where he +can be free from irksome pressure and from all sensations of sound and +light, but we can so arrange matters that he is not disturbed by loud +sounds and bright lights, and that he is not moved more than is +necessary. Sudden unexpected movements are especially harmful. Jogging +him up and down, patting him on the back, expostulation, and +entreaties are all out of place and do all the harm in the world. The +first bath should be as expeditious +<span class="pagenum">Page 106<a name="Page_106" id="Page_106"></a></span> +as possible, and above all the +baby must not be chilled by tedious exposure. Cold irritates his +nervous system more than anything else, unless it be excessive warmth. +In preserving the proper temperature so that we do not render the +child restless by excess of heat or by excess of cold, we +too-civilised people have made our own difficulties. We have +exaggerated the completeness of the sudden separation of mother and +child which nature decrees. It is the function of all mother animals +to approximate the unstable temperature of the newly born to their own +by the close contact of their bodies, which provide just the proper +heat. Labour is nowadays so complicated and exhausting a process for +mothers that, all things considered, we are wise in completing the +separation of mother and child and in removing the baby to his own +cot. But the difficulty remains, and we must arrange that any +artificial heating needed is constant and of proper degree.</p> + +<p>If the baby is very restless and irritable, too wide awake and too +conscious of his surroundings, the all-important task of getting him +to the breast and getting him to draw the milk into the breast is apt +to be difficult. His sucking is a purely reflex and involuntary act. +It can be produced by anything which gently presses down the tongue, +and a finger placed in the proper position will provoke the movement +without the child's consciousness being aroused. The placid child +whose mind is at rest will suck well and strongly. If, on the other +hand, the brain is too much stimulated and the child is restless and +<span class="pagenum">Page 107<a name="Page_107" id="Page_107"></a></span> +irritable, the reflex act of suction is inhibited, and it is a +difficult matter to get the child to the breast. He is too eager, +mouthing, and gulping, and spluttering. Or sometimes his mental +sufferings seem too much for his appetite, and though wide awake and +crying loudly, he refuses to grasp the nipple, turning his head away +and wriggling blindly hither and thither. This effect of mental unrest +on the newborn infant is often disastrous, because it is one of the +common causes of the failure of women to nurse their children. This is +not the place to sketch in detail a scheme for the proper technique of +breast nursing, a matter which is much misunderstood at the present +day. It will be enough shortly to say that an efficient supply of milk +depends upon the complete and regular emptying of the breast. The +breasts of all mothers will secrete milk if strong and vigorous +suction is applied to the nipple by the child. If anything interferes +with suction, the milk does not appear or, if it has appeared, it +rapidly declines in amount. The mother's part is to a great extent a +passive one, provided that she can supply one essential—a nipple that +is large enough for the child to grasp properly. Within wide limits +what the mother eats or drinks, whether she be robust or whether she +has always been something of an invalid, matters not at all. A frail +woman may naturally not be able to stand the strain of nursing for +many months, but that is not here the point in question. We are +dealing only with the establishment of lactation and with the milk +supply of the early days and weeks which is +<span class="pagenum">Page 108<a name="Page_108" id="Page_108"></a></span> +of such vital importance +for the child. If the mother is ill, if, for example, she has +consumption, we may separate her from the child in the interests of +both; but if this is not done, she will continue to secrete milk for a +time as readily as if she were in perfect health, and the breasts of +many a dying woman are to be seen full of milk. Mothers are too apt to +attribute the disappointment of a complete failure to nurse to some +weakness or want of robustness in their own health. This is never the +reason of the failure, and the fault, if the mother has a well-formed +nipple, is generally to be found in some disturbance in the child. +Prematurity, with extreme somnolence, breathlessness from respiratory +disease, nasal catarrh, which hinders breathing through the nose, +infections of all sorts, are common causes of this failure to suck +effectively. But perhaps the most common cause of all is the +inhibition from nervous unrest of that reflex act of sucking which +works so well in the placid and quiet child. It is a point to which +too little attention is paid, and mothers and the books which mothers +read commonly neglect the nervous system of the child and devote +themselves to such considerations as the relative merits of two-hourly +and four-hourly feedings—important points in their way, but less +important than this.</p> + +<p>The matter is complicated in two other ways. In the first place, the +nervous baby, just because he is so active and wakeful and restless, +is apt rapidly to lose weight and to have an increased need for food. +The restlessness is generally attributed to +<span class="pagenum">Page 109<a name="Page_109" id="Page_109"></a></span> +hunger, and this is true, +because hunger is soon added to the other sensations from which he +suffers, and like them is unduly acute. It is difficult not to give +way and to provide artificial food from the bottle. Yet if we do so we +must face the fact that these restless little mortals are quicker to +form habits than most, and once they have tasted a bottle that flows +easily without hard suction, they will often obstinately refuse the +ungrateful task of sucking at a breast which has not yet begun to +secrete readily. The suction that is devoted to the bottle is removed +from the breast, and the natural delay in the coming in of the milk is +increased indefinitely. At the worst, the supply of milk fails almost +at its first appearance. We must devote our attention to quieting the +nervous unrest by removing all unnecessary sensory stimulation from +the baby. He must be in a warm cot, in a warm, well-aired, darkened, +and silent room, and the necessary handling must be reduced to a +minimum. Sometimes sound sleep will come for the first time if he is +placed gently in his mother's bed, close to her warm body. If he is +apt to bungle at the breast from eagerness and restlessness, it is not +wise always to choose the moment when he has roused himself into a +passion of crying to attempt the difficult task. So far as is possible +he should be carried to the breast when he is drowsy and sleepy, not +when he is crying furiously, and then the reflex sucking act may +proceed undisturbed.</p> + +<p>In the second place, we must guard against the ill effect which the +ceaseless crying of these nervous +<span class="pagenum">Page 110<a name="Page_110" id="Page_110"></a></span> +babies has upon the mother. She may +be so exhausted by the labour that her nerves are all on edge, and she +grows apprehensive and frightened over all manner of little things. +The tired mother is apt to fear that she will have no milk, and her +agitation grows with each failure on the part of the child. Now the +first secretion of milk is very closely dependent upon the nervous +system of the mother. We have said that within wide limits her +physical condition is of less importance, but her peace of mind is +essential. And so it is wise for some part of the day to keep the +nervous baby out of hearing of the mother, and so far as possible to +choose moments when the child is quiet to put him to the breast. A +nurse with a confident, hopeful manner will effect most; a fussy, +over-anxious, or despondent attitude will do untold harm. We shall +sometimes fail if the nervous unrest is very obstinate either in +mother or in child, but we shall fail less often if we diagnose the +cause correctly in the cases we are considering. Lastly, it is +possible to control the condition in both mother and child by the +careful use of bromide or chloral.</p> + +<p>It is not, of course, suggested that these drugs should be given +freely or as a routine to every hungry baby wailing for the breast, or +that we can hope to combat or ward off an inherited neuropathy by a +few doses of a sedative. There are, however, not a few babies in whom +there develops soon after birth a sort of vicious circle. They can +suck efficiently and digest without pain only when they sleep soundly. +If they are put to the +<span class="pagenum">Page 111<a name="Page_111" id="Page_111"></a></span> +breast after much crying and restlessness, +each meal is followed by flatulence, colic, and renewed crying. The +only effective treatment is to secure sleep and to carry a slumbering +or drowsy infant to the breast. Then the sucking reflex comes to its +own again, the breast is drained steadily and well, and digestion +proceeds thereafter without disturbance and during a further spell of +sleep. Two or three times in the day we may be forced, as meal-time +approaches, to cut short the restlessness of the child by giving a +teaspoonful of the following mixture:</p> + +<table cellspacing="2" cellpadding="4" border="0" summary="Mixture for restless child"> +<tr> + <td>Pot. brom., </td> + <td>grs. ii. [2 grains]</td> +</tr> +<tr> + <td>Chloral hydrate,</td> + <td>gr. i. [1 grain]</td> +</tr> +<tr> + <td>Syrup,</td> + <td><img src="images/minim.gif" width="30" height="29" alt="Symbol: minim" title="Symbol: minim" /> x. [10 minims]</td> +</tr> +<tr> + <td>Aq. menth. pip., ad </td> + <td><img src="images/dram.gif" width="16" height="24" alt="Symbol: dram" title="Symbol: dram" /> i. [1 dram]</td> +</tr> +</table> + +<p>After this has been taken the child should be laid down for a quarter +of an hour until soundly asleep. Then very gently he can be carried to +his mother and the nipple inserted. If in this way a few days of sound +sleep and less disturbed digestion can be secured, the difficulty will +in most cases permanently be overcome. The steadier suction and more +efficient emptying of the breast will promote a freer flow of milk, +and the deeper and more prolonged sleep will lower greatly the needs +of the child for food. Most of the babies who show this fault are +thin, meagre, and fidgety, and with some increase of muscular tone. +The head is held up well, the limbs are stiff, the hands clenched, the +abdomen retracted, with the outline of the recti muscles unusually +prominent. If we can +<span class="pagenum">Page 112<a name="Page_112" id="Page_112"></a></span> +relax this exaggerated state of nervous tension, +if we can help them to become fatter and to put on weight, the +dyspepsia will disappear with the other symptoms.</p> + +<p>It is a question still to be answered whether the rare conditions of +pyloric spasm and pyloric hypertrophic stenosis are not further +developments of the same disturbance. Certainly these grave +complications appear most commonly in infants with a pronounced +nervous inheritance, and, as might be expected, they are more commonly +found in private practice than among the hospital classes.</p> + +<p>In passing, we may note that there are babies who exhibit the opposite +fault, and in whom the contrary regimen must be instituted. Premature +children, children born in a very poor state of nutrition, and +children born with great difficulty, so that they are exhausted by the +violence of their passage into the world, are apt to show the opposite +fault of extreme somnolence. They are so little stimulated by their +surroundings, and they sleep so profoundly, that the sucking reflex is +not aroused. Put to the breast they continue to slumber, or after a +few half-hearted sucking movements relapse into sleep. We must rouse +such children by moving them about and stirring them to wakefulness +before we put them to the breast.</p> + +<p>Once the child has been got to the breast, once the milk has become +firmly established, we have overcome the first great difficulty which +besets us in the management of nervous little babies, but it is by no +means the last. Restlessness and continual +<span class="pagenum">Page 113<a name="Page_113" id="Page_113"></a></span> +crying must be combated or +digestion suffers, and may show itself in a peculiar form of explosive +vomiting, which betokens the reflex excitability and unrest of the +stomach.</p> + +<p>The sense of taste is as acute as all other sensations. If the child +is bottle-fed, the slightest change in diet is resented because of the +unfamiliar taste, and the whole may promptly be rejected. The tendency +to dyspeptic symptoms is apt to lead to much unwise changing of the +diet, and everything tried falls in turn into disrepute, until perhaps +all rational diets are abandoned, and some mixture of very faulty +construction, because of its temporary or accidental success, becomes +permanently adopted—a mixture perhaps so deficient in some necessary +constituent that, if it is persisted with, permanent damage to the +growth of the child results. We must pay less attention to changes of +diet and explore our management of the child to try and find how we +can make his environment more restful.</p> + +<p>It is wise to accustom a nervous child from a very early age to take a +little water or fruit juice from a spoon every day. Otherwise when +breast-feeding or bottle-feeding is abandoned one may meet with the +most formidable resistance. Infants of a few months can be easily +taught; the resistance of a child of nine months or a year may be +difficult to overcome. The difficulty of weaning from the breast +recurs with great constancy in nervous children. By this time the +influence of environment has become clearly apparent. The child is +often enough already master of the situation, +<span class="pagenum">Page 114<a name="Page_114" id="Page_114"></a></span> +and is conscious of his +power. Such children will sometimes prefer to starve for days +together, obstinately opposing all attempts to get them to drink from +a spoon, a cup, or even a bottle. When this happens, sometimes the +only effective way is to change the environment and to send the baby +to a grandmother or an aunt, where in new surroundings and with new +attendants the resistance which was so strong at home may completely +disappear. When weaning is resented, and difficulties of this sort +arise, it is clear that the mother, whose breast is close at hand, is +at a great disadvantage in combating the child's opposition.</p> + +<p>For nervous infants, alas! broken sleep is the rule. What, then, is to +be done? It is astonishing to me that any one who has studied the +behaviour of only a few of these nervous and restless infants should +uphold the teaching that the crying of the young infant is a bad +habit, and that the mother who is truly wise must neglect the cry and +leave him to learn the uselessness of his appeals. It is true that the +youngest child readily contracts habits good or bad. Either he will +learn the habit of sleep or the habit of crying. Mercifully the +inclination of the majority is towards sleep. But to encourage habits +of restlessness and crying there is no surer way than to follow this +bad advice and to permit the child to cry till he is utterly exhausted +in body and in mind. It is unwise <i>always</i> to rock a baby to sleep; it +is also unwise to allow him to scream himself into a state of +hysteria. A quiet, darkened room, the steady pressure of the mother's hand in +<span class="pagenum">Page 115<a name="Page_115" id="Page_115"></a></span> +some rhythmical movement, will often quiet an incipient +storm. The longer he cries, the more trouble it is to soothe him. +Sleep provokes sleep, so that often we find restlessness and sound +sleep alternating in a sort of cycle, a good week perhaps following a +bad one. The nurse who is quick to cut short a storm of crying and to +soothe the child again to sleep is helping him to form habits of +sleep. The nurse who leaves him to cry, believing that in time he will +of his own accord recognise the futility of his behaviour, is making +him form habits of crying. A rigid routine in sleep is a good thing, +but the routine belongs to the baby, not to the nurse. The child must +be educated to sleep, not taught to cry. A baby has but little power +of altering his position when it becomes strained or uncomfortable. He +cannot turn over and nestle down into a new posture. If we watch him +wake, the first stirring may be very gradual, and in a moment he may +fall again to sleep. A few minutes later he stirs again more strongly, +and is wider awake and for longer. It may only be after a third +waking, by a summation of stimuli, that he is finally roused and +breaks into loud crying. The nurse who is on the watch, who, sleeping +beside him, wakes at the slightest sound and is quick to turn him over +and settle him into a new position of rest, will probably report in +the morning that the baby has had a good night. The nurse who lets the +child grow wide awake and start crying loudly, will spend perhaps many +hours before quiet is again restored. Of the voluntary, purposive +crying of infants a little older +<span class="pagenum">Page 116<a name="Page_116" id="Page_116"></a></span> +I am not here speaking. Infants in +the second six months are quite capable of establishing a "Tyranny of +Tears" and feeling their power. Fortunately it requires no great +experience to distinguish one from the other, and to adopt for each +the appropriate treatment.</p> + +<p>Again, in elementary teaching upon the management of infants stress is +laid, rightly enough, upon the importance of regularity in the times +of feeding, and on the observance in this respect also of a very +strict routine. But in the case of the very nervous infant a certain +latitude should be allowed to an experienced nurse or mother. We may +wreck everything by a blind adhesion to a too rigid scheme, which may +demand that we leave the child to scream for an hour before his meal, +or that, when at length he has fallen into a sound sleep after hours +of wakefulness, we should proceed to wake him.</p> + +<p>Symptoms of dyspepsia which are due to continued nervous excitement +demand treatment which is very different from that which would be +appropriate to dyspepsia which is due to other causes, such as +overfeeding or unsuitable feeding. The temporary restriction of food, +which is commonly ordered in dyspepsia from these causes, is very +badly supported by the nervous infant. Hunger invariably increases the +unrest, and the unrest increases the dyspepsia.</p> + +<p>The difficulties of managing a nervous infant are very real, and call +for the most exemplary patience on the part of the mother and the +clearest insight into the nature of the disturbance.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 117<a name="Page_117" id="Page_117"></a></span></p> + +<h3>CHAPTER IX</h3> + +<h3>MANAGEMENT IN LATER CHILDHOOD</h3> + + +<p>In the early days in the nursery the actions of the infant, for the +most part, follow passively the traction exercised by nurses and +mothers, sometimes consciously, but more often unconsciously. We have +now to consider a period when the child becomes possessed of a driving +force of his own, and moves in this direction or that of his own +volition. In this new intellectual movement through life he will not +avoid tumbles. He will feel the restraints of his environment pressing +upon him on all sides, and he will often come violently in contact +with rigid rules and conventions to which he must learn to yield. From +time to time we read in the papers of some terrible accident in a +picture-palace, or in a theatre. Although there has been no fire, +there has been a cry of fire, and in the panic which ensues lives are +lost from the crowding and crushing. Yet all the time the doors have +stood wide open, and through them an orderly exit might have been +conducted had reason not given place to unreason. It is the task of +those responsible for the children's education to guide them without +wild struggling along the paths of +<span class="pagenum">Page 118<a name="Page_118" id="Page_118"></a></span> +well-regulated conduct towards the +desired goal, influenced not by the emotions of the moment, but only +by reason and a sense of right; not ignorant of the difficulties to be +met, but practised and equipped to overcome them.</p> + +<p>It is easy thus to state in general terms the objects of education, +and the need for discipline. To apply these principles to the +individual is a task, the immeasurable difficulty of which we are only +beginning to appreciate with the failure of thirty years of compulsory +education before us. A recent writer<a name="FNanchor_2_2" id="FNanchor_2_2" /> +<a href="#Footnote_2_2" class="fnanchor">[2]</a> gives it as his opinion that +the aim of education is to equip a child with ideals, and that this +task should not be difficult, because the lower savages successfully +subject all the members of their tribe to the most ruthless +discipline. Their lives, he says, "are lived in fear, in restraint, in +submission, in suffering, subject to galling, unreasoning, +unnecessary, arbitrary prohibitions and taboos, and to customary +duties equally galling, unreasoning, unnecessary, and arbitrary. They +endure painful mutilations, they submit to painful sacrifices.... How +are these wild, unstable, wayward, impulsive, passionate natures +brought to submit to such a rigorous and cruel discipline? By +education; by the inculcation from infancy of these ideals. In these +ideals they have been brought up, and to them they cling with the +utmost tenacity." One might as well contend that it was easy to teach +all men to live the self-denying life of earnest Christians because +some savage tribe was successful in main +<span class="pagenum">Page 119<a name="Page_119" id="Page_119"></a></span> +taining among its members a +universal and orthodox worship of idols. The ideals set before the +child are too high and too complex to be inculcated by physical force, +or even by force of public opinion. A rigid discipline, with many +stripes and with terrible threats of a still worse punishment in the +world to come, was the almost invariable lot of children until the +last century was well advanced. Yet has this drastic treatment of +young children fulfilled its purpose? Were the men of fifty years ago +better conducted and more controlled than the men of to-day? In any +one family did a greater proportion turn out well? Is it not true that +at least among the educated classes the relaxation of nursery and +schoolroom discipline which the last fifty years has seen has been +justified by its results? Is it not true that the childhood of our +grandmothers was often lived "in fear, in restraint, in submission, in +suffering subject to galling, unreasoning, unnecessary, arbitrary +prohibitions and taboos, and to customary duties equally galling, +unreasoning, unnecessary, and arbitrary." And though perhaps the +grandmothers of most of us may not have been much the worse for all +this discipline, is it not true that of the little brothers who shared +the nursery with them a surprising number broke straightway into +dissipation when the parental restraints were removed? If we are to +teach a child to be gentle to the weak it is not wise to beat him. The +qualities which we wish him to possess are not more subtle than the +means by which we must aid him to their possession.</p> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2" /><a href="#FNanchor_2_2"> +<span class="label">[2]</span></a> <i>The Principles of Rational Education</i>, by Dr. C.A. +Mercier.</p></div> + +<p>Education comprises physical, mental, and moral +<span class="pagenum">Page 120<a name="Page_120" id="Page_120"></a></span> +training. In earlier +times physical strength and the power to fight well, alone were prized +and were the chief objects to be gained in the education of youth. +Later, under the stress of intellectual competition for success in +life, mental acquirements have come to occupy the first place. We are +only now learning to lay emphasis upon the supreme need for moral +training. Not that it is possible to separate the sum of education +into its constituent parts, and to regard each as distinct from the +others. That many men of great intellectual activity, and many men +pre-eminent for their moral qualities have harboured a great brain or +a noble character in a weakly or deformed body, forms no argument to +disprove the general rule that a healthy, vigorous physique is the +only sure foundation upon which to build a highly developed intellect +and a stable temperament. In childhood the intimate connection between +vigour of mind and vigour of body is almost always clearly shown. A +child with rickets, unable to exercise his body in free play, as a +rule shows a flabbiness of mind in keeping with his useless muscles +and yielding bones. Such children talk late, are infantile in their +habits and ways of thought, and are more emotional and unstable than +healthy children of the same age. The connection between bodily +ailments and instability of nervous control is even more clearly seen +in the frequent combination of rheumatism and chorea. A very high +proportion of older children suffering from the graver neuroses, such +as chorea, syncopal attacks, phobias, tics, and so forth, show defective physical +<span class="pagenum">Page 121<a name="Page_121" id="Page_121"></a></span> +development. Scoliosis, lordosis, knock-knee, flat +foot, pigeon chest, albuminuria, cold and cyanosed extremities, are +the rule rather than the exception. If the body of the child is +developed to the greatest perfection of which it is capable we shall +not often find a too sensitive nervous system. The boy of fine +physique may have many faults. He may be bad-tempered or untruthful or +selfish, but such faults as he has are as a rule more primitive in +type, more readily traced to their causes, and more easy to eradicate +than the faults which spring from that timidity, instability, and +moral flabbiness which has so often developed in the lax delicate +child reared softly in mind and body.</p> + + +<p class="subhead">Physical Training</p> + +<p>Children thrive best in the healthy open-air life of the country, and +if there is any tendency to nervous disturbances the need for this +becomes insistent. Physical training, further, includes the manual +education of the child. The system of child-training advocated by Dr. +Montessori is based upon the cultivation of tactile sensations and the +development of manual dexterity. Exercises such as she has devised +have an immediate effect in calming the nervous system and in changing +the restless or irritable child into a self-restrained and eager +worker. Lord Macaulay, whose phenomenal memory as a child has become +proverbial, was so extraordinarily unhandy that throughout life he had +considerable difficulty in putting on his gloves, +<span class="pagenum">Page 122<a name="Page_122" id="Page_122"></a></span> +while he had such +trouble with shaving that on his return from India there were found in +his luggage some fifty razors, none of which retained any edge, and +nearly as many strops which had been cut to pieces in his irritated +and ineffectual efforts. If we teach a child manual dexterity it is an +advantage to him, because manual dexterity is seldom associated with +restlessness and irritability of mind. To excel in some handicraft not +only bespeaks the possession of self-control, it helps directly to +cultivate it. The teaching of Froebel and Montessori holds good after +nursery days are over.</p> + + +<p class="subhead">Mental Training</p> + +<p>Mental training enables the child to retain facts in his memory, to +obtain information from as many sources as possible, to understand and +piece them together, and finally to reach fresh conclusions from +previously acquired data. So far as is possible the teacher must +satisfy the natural desire to know the reason of things. It must be +his endeavour to prevent the child from accepting any argument which +he has not fully understood, and which, as a result, he is able not to +reconstruct but only to repeat. Mental work which is slovenly and +perfunctory is as harmful to the child's education as mechanical work +which is bungled and ineffective. Taking advantage of his natural +aptitudes, his interest should be developed and extended in every way +possible. Tasks which are accomplished without enthusiasm are labour +expended in vain, +<span class="pagenum">Page 123<a name="Page_123" id="Page_123"></a></span> +because the knowledge so acquired is not +assimilated and adds nothing to the child's mental growth. There +should be no sharp differentiation between work and play.</p> + + +<p class="subhead">Moral Training</p> + +<p>Moral training depends upon the force of example rather than of +precept. Parents must be scrupulously just and truthful to the child, +for his quick perception will detect the slightest deceit, and the +evil impression made on his mind may be lasting. They must confidently +expect conduct from him of a high moral standard, and be careful at +this early age to avoid the common fault of giving a dog a bad name. +If it is said on all sides that a child has an uncontrollable temper, +is an inveterate grumbler, is lacking in all power of concentration, +or has a tendency to deceit, it is likely that the child will act up +to his reputation. He comes in time to regard this failing of his as +part of himself just as much as is the colour of his hair or the +length of his legs. It may be said of a schoolboy that he shows no +aptitude for his work. Term by term the same report is brought home +from school, and each serves only to confirm the boy in his belief +that this failing is part of his nature, and that no effort of his own +can correct it. If one subject only has escaped the condemnation of +his master, then it may be to that study alone that he returns with +zest and enjoyment. Spendthrift sons are manufactured by those fathers +who many times a day proclaim that the boy has no notion of the value +of money.</p> + +<p><span class="pagenum">Page 124<a name="Page_124" id="Page_124"></a></span> +And so with children! Parents must take it for granted that they will +display all the virtues they desire in them. They must trust to their +honour always to speak the truth, and always to do their best in work +or play whether they are with them or not. Again and again the +children will fail and their patience will be tried to the utmost. +They must explain how serious is the fault, and for the time being +their trust may have to be removed; but with the promise of amendment +it must again be fully restored and the lapse completely forgotten. If +the child feels he is not trusted he ceases to make any effort, and +lapse will succeed lapse with increasing frequency.</p> + +<p>In efforts at moral training there is often too great an emphasis laid +upon negative virtues. It is wrong to do this: to do that is +forbidden. Children cannot progress by merely avoiding faults any more +than a man may claim to be an agreeable companion at table because he +does not eat peas with a knife or drink with his mouth full. There +must be a constant effort to achieve some positive good, to acquire +knowledge, to do service, to take thought for others, to discipline +self, and the parent will get the best result who is comparatively +blind to failure but quick to encourage effort and to appreciate +success. When the child knows well that he is doing wrong, exhortation +and expostulation are usually of little avail if repeated too often, +and serious talks should only take place at long intervals.</p> + +<p>We know how effective the so-called "therapeutic +<span class="pagenum">Page 125<a name="Page_125" id="Page_125"></a></span> +conversation" may be +in helping some overwrought and nervously exhausted man or woman to +regain peace of mind and self-control. After an intimate conversation +with a medical man who knows how to draw from the patient a free +expression of the doubts, anxieties, and fears which are obsessing +him, many a patient feels as though he had awakened in that instant +from a nightmare, and passes from the consulting-room to find his +troubles become of little account. Not a few patients return to be +reassured once more, and derive new strength on each occasion. Yet +visits such as these must be infrequent or they will lose their power. +Now, just as the physician is well aware that his intervention if too +frequently repeated will lose its effect, so the parent must be chary +of too frequent an appeal to the moral sense of the child. At long +intervals opportunity may be taken with all seriousness to set before +the child ideals of conduct, to-speak to him of the meaning of +character and of self-discipline, and of the standards by which we +judge a man or woman to be weak and despicable, or strong and to be +admired. The effect of such an intimate conversation, never repeated, +may persist throughout life. Constantly reiterated appeals, on the +other hand, do more harm than good. To tell a child daily that he is +"breaking mother's heart," or that he is "disappointing his father," +is to debase the moral appeal and deprive it of its strength.</p> + +<p>For everyday use it is best to cultivate a manner which can indicate +to the child that he is for the +<span class="pagenum">Page 126<a name="Page_126" id="Page_126"></a></span> +moment unpopular, but which at the +same time denies to the small sinner the interest of attempting his +own defence. On the other hand, should the child be reasonably in +doubt as to the nature of his offence we must spare no trouble in +explaining it to him. Punishment will be most effective when the child +is convinced that he is rightly convicted. If it is to act as a real +deterrent, he must agree to be punished—a frame of mind which, if it +can be produced, may be welcomed as a sure sign that training is +proceeding along the right lines.</p> + +<p>By physical training, mental training, and moral training the child's +character is formed and self-discipline is developed. With the child +of neuropathic disposition and inheritance matters may not proceed so +smoothly. Reasoning and conduct may be alike faulty, and the nervous +disturbances may even cause detriment to the physical health. Not that +the nervous child requires an environment different from that of the +normal child. The difficulties which the parents will encounter and +the problems which must be solved differ not in kind but in degree. An +error of environment which is without effect in the normal child may +be sufficient to produce disastrous results in the neuropathic.</p> + +<p>It must be granted that there are some unfortunate children in whom +the moral sense remains absent and cannot be developed—children who +steal and lie, who seem destitute of natural affection, or who appear +to delight in acts of cruelty. These moral degenerates need not be +considered here. Serious errors of conduct, however, in children who are not +<span class="pagenum">Page 127<a name="Page_127" id="Page_127"></a></span> +degenerate or imbecile, frequently arise directly from faults +of management and can be controlled by correcting these faults. +Suppose, for example, that a child is found to have taken money not +his own. The action of the parents faced with this difficulty and +disappointment will determine to a great extent whether the incident +is productive of permanent damage to the child's character. The +peculiar circumstances of each case must be considered. For example, +the parent must bear in mind the relation in which children stand to +all property. The child possesses nothing of his own; everything +belongs in reality to his father and mother, but of all things +necessary for him he has the free and unquestioned use. Unless his +attention has been specially directed to the conception of ownership +and the nature of theft, he may not have reasoned very closely on the +matter at all. Very probably he knows that it is wrong to take what is +not given him, but he does not regard helping himself to some dainty +from a cupboard as more than an act of disobedience to authority. He +may have imbibed no ideas which place the abstraction of money from a +purse belonging to his parents on a different plane, and which have +taught him to regard such an action as especially dishonourable and +criminal. Finally, a child who, undetected, has more than once taken +money belonging to his father and mother, may pass without much +thought to steal from a visitor or a servant. To deal with such a case +effectively, to ensure that it shall never happen again, requires much +insight. If the father, +<span class="pagenum">Page 128<a name="Page_128" id="Page_128"></a></span> +shocked beyond measure to find his son an +incipient criminal, differing in his guilt in no way from boys who are +sent to reformatories as bad characters, convinces the child that +although he did not realise it, he has shown himself unworthy of any +further trust, untold harm will be done. Almost certainly the child +will act in the future according to the suggestions which are thus +implanted in his mind. If the household eyes him askance as a thief, +if confidence is withdrawn from him, he sees himself as others see him +and will react to the suggestions by repeating the offence. The +seriousness of what he has done should be explained to him, and after +due punishment he must be restored completely and ostentatiously to +absolute trust. Only by showing confidence in him can we hope to do +away with the dangers of the whole incident. To inculcate good habits +and encourage good behaviour we must let the child build up his own +reputation for these virtues. It need not make him priggish or +self-satisfied if parents let him understand that they take pride in +seeing him practise and develop the virtue they aim at. For example, +it is desired above all that he should always speak the truth. Then +they must ostentatiously attach to him the reputation of truthfulness +and show their pride in his possessing it. If he falls from grace they +must remember that he is still a child, and that if that reputation is +lightly taken from him and he is accused of a permanent tendency +towards untruthfulness, he is left hopeless and resigned to evil. Let +any mother make the experiment of presenting +<span class="pagenum">Page 129<a name="Page_129" id="Page_129"></a></span> +to her child in this way +a reputation for some particular virtue. For example, if an older +child shows too great a tendency to tease and interfere with the +younger children, let the mother seize the first opportunity which +presents itself to applaud some action in which he has shown +consideration for the others. Let her comment more than once in the +next few days on how careful and gentle the older child is becoming in +his behaviour to the little ones, and in a little the suggestion will +begin to act until the transformation is complete. If, on the other +hand, the mother adopts the opposite course and rebukes the child for +habitual unkindness, she will be apt to find unkindness persisted in. +The criminal records of the nation show too often the truth of the +saying that "Once a thief always a thief." Deprived of his good +repute, man loses his chief protection against evil and his incentive +to good.</p> + +<p>The inability of a child—and especially of a nervous and sensitive +child—to form conceptions of his own individuality except from ideas +derived from the suggestions of others, gives us the key to our +management of him and to our control of his conduct. He has, as a +rule, a marvellously quick perception of our own estimate of him, and +unconsciously is influenced by it in his conception of his own +personality, and in all his actions. Parents must believe in his +inherent virtue in spite of all lapses. If they despair it cannot be +hid from the child. He knows it intuitively and despairs also. It is +then that they call him incorrigible. If it +<span class="pagenum">Page 130<a name="Page_130" id="Page_130"></a></span> +happens that one parent +becomes estranged from the child, despairs of all improvement, and +sees in all his conduct the natural result of an inborn disposition to +evil, while the other parent holds to the opinion that the child's +nature is good, and to the belief that all will come right, then often +enough the child's conduct shows the effect of these opposite +influences. In contact with the first he steadily deteriorates, +affording proof after proof that judgment against him has been rightly +pronounced. In contact with the other, though his character and +conduct are bound to suffer from such an unhappy experience, he yet +shows the best side of his nature and keeps alive the conviction that +he is not all bad.</p> + +<p>The force of suggestion is still powerful to control conduct and +determine character in later childhood. The impetus given by the +parents in this way is only gradually replaced by the driving power of +his own self-respect—a self-respect based upon self-analysis in the +light of the greater experience he has acquired.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 131<a name="Page_131" id="Page_131"></a></span></p> + +<h3>CHAPTER X</h3> + +<h3>NERVOUSNESS IN OLDER CHILDREN</h3> +<p> </p> + +<p>In older children the line which separates naughtiness, fractiousness, +and restlessness from definite neuropathy begins to be more marked. +The nature of the young child, taking its colour from its +surroundings, is sensitive, mobile, and inconstant. With every year +that passes, the normal child loses something of this impressionable +and fluid quality. With increasing experience and with a growing power +to argue from ascertained facts, character becomes formed, and if +tempered by discipline will come to present a more and more unyielding +surface to environment, until finally it becomes set into the +stability of adult age.</p> + +<p>We may perhaps, with some approach to truth, look upon the adult +neurotic as one whose character retains something of the +impressionable quality of childhood throughout life, so that, to the +last, environment influences conduct more than is natural.</p> + +<p>All the emotions of neurotic persons are exaggerated. Disappointments +over trifles cause serious upsets; grief becomes overmastering. +Violent and perhaps ill-conceived affection for +<span class="pagenum">Page 132<a name="Page_132" id="Page_132"></a></span> +individuals is apt to +be followed by bitter dislike and angry quarrelling. On the physical +side, sense perception is abnormally acute, and many sensations which +do not usually rise up into consciousness at all become a source of +almost intolerable suffering. To these most unhappy people summer is +too hot and winter too cold; fresh air is an uncomfortable draught, +while too close an atmosphere produces symptoms of impending +suffocation.</p> + +<p>In some neurotics there is an excessive interest in all the processes +of the life of the body, and when attention is once attracted to that +which usually proceeds unconsciously, symptoms of discomfort are apt +to arise. Thus so simple an act as swallowing may become difficult, or +for the time being impossible. To breathe properly and without a sense +of suffocation may seem to require the sustained attention of the +patient; or again, the voice may be suddenly lost.</p> + +<p>More commonly, perhaps, neuropathy exhibits itself in an undue +tendency to show signs of fatigue upon exertion of any sort, mental or +physical. Sustained interest in any pursuit or task becomes +impossible. Nameless fears and unaccountable sensations of dread +establish themselves suddenly and without warning, and may be +accompanied on the physical side by palpitation, flushing, headache, +or acute digestive disturbances.</p> + +<p>All these manifestations are best controlled by selecting a suitable +environment, and as a rule the character of the environment is +determined by the temperament and disposition of those who live +<span class="pagenum">Page 133<a name="Page_133" id="Page_133"></a></span> +in close contact with the patient. Like the tiny children with whom we +have dealt so far, the behaviour of neuropathic persons is subject +wholly to the direction of stronger and more dominant natures. With +faulty management at the hands of those around them, no matter how +loving and patient these may be, the conduct of the neurotic tends to +become abnormal.</p> + +<p>In children beyond earliest infancy we recognise a gradual approach to +the conditions of adult life. Fractiousness and naughtiness, +ungovernable fits of temper, inconsolable weeping and inexplicable +fears should disappear with early childhood even if management has not +been perfect. If they persist to older childhood we shall find in an +increasing percentage of cases evidence of definite neuropathic +tendencies which urgently call for investigation and for a precise +appreciation of the nature of the abnormality. It may be that the only +effective treatment is that which we recognise as essential in the +grosser mental disturbances—removal from the surroundings in which +the abnormal conduct has had free play, and separation from the +relatives whose anxiety and alarm cannot be hidden.</p> + +<p>In young nervous children fear is the most prominent psychical +symptom. The children are afraid of everything strange with which they +come in contact. They are afraid of animals, of a strange face, or an +unfamiliar room. Older children usually manage to control themselves, +suppress their tears, and prevent themselves from +<span class="pagenum">Page 134<a name="Page_134" id="Page_134"></a></span> +crying out, but it is nevertheless easy to detect the struggle.</p> + +<p>Often we find those distressing attacks to which the name +"night-terrors" has been given. The child wakes with a cry,—usually +soon after he has gone to sleep,—sits up in bed and shows signs of +extreme terror, gazing at some object of his dreams with wide-open +startled eyes, begging his nurse or mother to keep off the black dog, +or the man, or whatever the vision may be. Even after the light is +turned up and the child has been comforted, the terror continues, and +half an hour may elapse before he becomes quiet and can be persuaded +to go back to bed. In the morning as a rule he remembers nothing at +all.</p> + +<p>Phobias of all sorts are common in nervous children, and result from a +morbid exaggeration of the instinct for self-preservation. Some cannot +bear to look from a height, others grow confused and frightened in a +crowd; dread of travelling, of being in an enclosed space such as a +church or a schoolroom, or of handling sharp objects may develop into +a constant obsession. I have known a little girl who was seized with +violent fear whenever her father or mother was absent from the house, +and she would stand for hours at the window in an agony of terror lest +some harm should have befallen them. As if with some strange notion of +propitiating the powers of darkness these children will often +constantly perform some action and will refuse to be happy until they +have done so. The same little girl who suffered such torments of anxiety +<span class="pagenum">Page 135<a name="Page_135" id="Page_135"></a></span> +in her parents' absence would always refuse to go to bed +unless she had stood in turn on all the doormats on the staircase of +her home. Other children feel themselves forced to utter certain words +or to go through certain rhythmical movements. They fully understand +that the fear in their mind is irrational and devoid of foundation, +but they are unable to expel it. Often it is hugged as a jealous +secret, so that the childish suffering is only revealed to others +years afterwards, when adult age has brought freedom from it. We will +do well to try by skilful questioning to gain an insight into the +mental processes of a child when we find him showing an uncontrollable +desire to touch lamp-posts or to stand in certain positions; or when +he develops an excessive fear of getting dirty, or is constantly +washing his hands to purify them from some fancied contamination.</p> + +<p>The treatment of all these symptoms calls for much insight. The +child's confidence must be completely secured, and he must be +encouraged to tell of all his sensations and of the reasons which +prompt his actions. The nervous child has a horror of appearing unlike +other children, and will suffer in silence. If his troubles are +brought into the light of day with kindness and sympathy they will +melt before his eyes. Even night-terrors are, as a rule, determined by +the suppressed fears of his waking hours. If they are provoked by his +experiences at school, by the fear of punishment or by dismay at a +task that has proved beyond his powers, he should be taken away from school for +<span class="pagenum">Page 136<a name="Page_136" id="Page_136"></a></span> +the time being. Night-terrors are said to be aggravated by +nasal obstruction due to adenoid vegetations. Clothing at night should +be light and porous, and particular attention should be paid to the +need for free ventilation.</p> + +<p>We have spoken in an earlier chapter of the trouble sometimes +experienced in inducing a nervous child to go to sleep. In older +children insomnia is common enough. Even when sleep comes it may be +light and broken, as though the child slept just below the surface of +consciousness and did not descend into the depths of sound and +tranquil slumber. We have often noticed how different is the estimate +of the patient from that of the nurse as to the number of hours of +sleep during the night. The sick man maintains that he has hardly +slept at all, whilst the nurse, drawing us aside, whispers in our ear +that he has slept most of the night. In estimating sleep we have to +consider not only its duration, but also its depth, and the patient +who denies that he has slept at all has lain perhaps half the night +with an active restless brain betwixt sleep and wakefulness. Often +enough when he comes to consider in the morning the problems that +vexed his soul at midnight, he is quite unable to recall their nature, +and recognises them as the airy stuff that dreams are made of. +Although in a sense asleep he may have retained a half-consciousness +of his surroundings and a sense of despair at the continued absence of +a sounder sleep.</p> + +<p>With nervous children we are apt to find sleep +<span class="pagenum">Page 137<a name="Page_137" id="Page_137"></a></span> +which is of little depth and which constantly shows evidence of a too-active brain. The +body is tossed to and fro, words are muttered, and the respiration is +hurried and with a change in rhythm, because there is no depth of +anæsthesia. The body still responds to the impulses of the too-active +brain. From the nature of his dream—as shown by chance words +overheard—we may sometimes gather hints to help us to find where the +elements of unrest in his daily life lie. Sleep-walking is only a +further stage in this same disorder of sleep, in which the dream has +become so vivid that it is translated into motor action.</p> + +<p>If a child begins to suffer from active sleeplessness we must not make +the mistake of urging him to sleep. He is no more capable than we are +ourselves of achieving sleep by an effort of will power. To urge him +to sleep is likely to cause him to keep awake because we direct his +attention to the difficulty and make him fear that sleep will not +come. If he understands that all that he needs is rest, he will +probably fall asleep without further trouble.</p> + +<p>Day-dreams also may become abnormal, and tell of an unduly nervous +temperament. Any one who watches a little child at play will realise +the strength of his power of imagination. The story of Red Riding Hood +told by the nursery fire excites in the mind of the child an +unquestioning belief which is never granted in later life to the most +elaborate efforts of the theatre. All this imaginative force is +natural for the child. It becomes abnormal only when things seen and +acts performed in imagination +<span class="pagenum">Page 138<a name="Page_138" id="Page_138"></a></span> +are so vivid as to produce the +impression of actual occurrences, and when the child is so under the +sway of his day-dreams that he fails to realise the difference between +pretence and reality. Imagination which keeps in touch with reality by +means of books and dolls and toys is natural enough. Not so +imagination which leads to communion with unseen familiars or to acts +of violence due to the organisation of "conspiracies" or "robber +bands" amongst schoolboys.</p> + +<p>If evidence of abnormal imagination appears, the child must be kept in +close touch with reality. We must give him interesting and rational +occupation, such as drawing, painting, the making of collections of +all sorts, gardening, manual work, and so forth. In older children we +must especially supervise the reading.</p> + +<p>In many nervous children we find a faulty contact with environment, so +that instead of becoming interested in the thousand-and-one happenings +of everyday life and experiences, they become introspective and +self-conscious. As a result, sensations of all sorts, which are +commonly insufficient to arouse the conscious mind, attract attention +and, rising into consciousness, occupy the interest to the exclusion +of everything else. The conscious mind is not capable of being +occupied by more than one thing at a time. If attention is +concentrated upon external matters, bodily sensations, even extreme +pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells +us, hardly feels the scalping-knife as he shouts his death song. +<span class="pagenum">Page 139<a name="Page_139" id="Page_139"></a></span> +The soldier in the excitement of battle is often bereft of all sense of +pain. On the other hand, the patient who is morbidly self-conscious +becomes oblivious of his surroundings while he suffers intensely from +sensations which are usually not appreciated at all. Self-conscious +children will complain much of breathlessness and a sense of +suffocation, of headache, of palpitation, of intolerable itching, of +the pressure of clothing, or of flushing and a sense of heat. +Excessive introspection influences their conduct in many ways. At +children's parties, for example, they will be found wandering about +unhappy, dazed and unable to feel the reality of the surroundings +which afford such joy to the others; or they may be anxious to join in +play, but finding themselves called upon to take their turn are apt to +stand helplessly inactive, or to burst into tears. At school, though +they may be really quick to learn, they will often be found oblivious +of all that has gone on around them, not from stupidity, but from +inability to dissociate their thoughts from themselves and to +concentrate attention upon the matter in hand. In such a case we must +aim at developing the child's interest to the exclusion of this morbid +introspection. Taking advantage of his individual aptitude, we must +strengthen his hold upon externals in every way possible, and we must +explain to him the nature of his failing and teach him that his +salvation lies in cultivating his capacity for paying attention to +things around him and developing an interest in suitable occupations.</p> + +<p><span class="pagenum">Page 140<a name="Page_140" id="Page_140"></a></span> +Fainting fits are not uncommon amongst nervous children from about +the sixth year onwards, and are apt to give rise to an unwarranted +suspicion of epilepsy. In other cases fears have been aroused that the +heart may be diseased. In children who faint habitually the nervous +control of the circulation is deficient. We notice that when they are +tired by play, or when they are suffering from the reaction that +follows excitement of any sort, the face is apt to become pale, and +dark lines may appear under the eyes. Yet there may be no true anæmia +present: it is only that the skin is poorly supplied with blood for +the moment. After a little rest in bed, or under the influence of a +new excitement, the colour returns, and the tired look vanishes. If +children of this type are made to stand motionless for any length of +time, and if at the same time there is nothing to attract their +interest or attention—a combination of circumstances which unhappily +is sometimes to be found during early morning prayers at school—the +want of tone in the blood vessels may leave the brain so anaemic that +fainting follows. The first fainting attack is a considerable +misfortune, because the fear of a recurrence is a potent cause of a +repetition. Standing upright with the body at rest and the mind +vacant, the circulation stagnates, the boy's mind is attracted by the +suggestion, he fears that he will faint as he has done before, and he +faints. Schoolmasters are well aware that if one or two boys faint in +chapel and are carried out, the trouble may grow to the proportion of +a veritable epidemic. It is important +<span class="pagenum">Page 141<a name="Page_141" id="Page_141"></a></span> +that this habit of fainting +should be combated not only by general means to improve the tone of +the body and circulation, but also by taking care that the child +understands the nature of the fainting fit, and the part which +association of ideas plays in producing it. Disease of the heart +seldom gives rise to fainting.</p> + +<p>The same vasomotor instability which shows itself in the tendency to +syncopal attacks is apparent in many other ways. Sudden sensations of +heat and of flushing, equally sudden attacks of pallor, coldness of +the extremities, abundant perspiration,—raising in the mind of the +anxious mother the fear of consumption,—and excessive diuresis are +common accompaniments. A further group of symptoms is provided by the +extreme sensibility of the digestive apparatus. Dyspepsia, +hyperaesthesia of the intestinal tract, viscero-motor atonies and +spasms, and anomalies of the secretions, whether specific like that of +the gastric juice or indifferent like that of the nasal, pharyngeal, +gastric, and intestinal mucus, are all of common occurrence. Whenever +the nervous child is subjected to any exhausting experience, any +excitement, pleasurable or the reverse, or any undue exertion, whether +mental or physical, one may note the subsequent gastro-intestinal +derangement, including even a coating of the tongue. The slightest +deviation from the usual diet, the most trivial fatigue, a chill of +the body, even a change in the temperature of the food may set loose +the most extreme reactions in the gastro-intestinal tract—motor, +sensory, or secretory. +<span class="pagenum">Page 142<a name="Page_142" id="Page_142"></a></span> +It is not an accident that so often the mucous +diarrhoea, which may have afflicted an excitable child in London for +many months, and which a visit to the seaside, with all its healthy +activities, may seem to have completely cured, relapses within a day +or two of the return to the restricted environment and uninteresting +routine of life in London. The child who was happy and busy and at +peace with himself, at play in the open air, resents the sudden +cessation of all this, and the nervous unrest returns. To attempt +treatment by dietetic restrictions alone is to deal only with a +symptom. The gastro-intestinal reactions are so violent that the +parents are generally voluble on the subject of the many foods which +cannot be taken and the few which are not suspect. To prescribe rigid +tables of diet is to add to the alarm of the mother, and to sustain +her in the belief that the child is in daily danger of being poisoned +by a variety of common articles of diet. Only by lowering the +excitability of the nervous system, by occupying the mind and giving +strength to the child's powers of control can we effectively combat +the hyperaesthesia. If necessary the personnel of the management of +the child will have to be altered. There may be no other way to +achieve certain and rapid improvement in a condition which is causing +grave danger to the child and very genuine distress and suffering to +the parents. A violent reaction to intoxications of all sorts is a +further stigma of nervous instability. Sudden and even inexplicable +rises of temperature are frequent complaints, and the constitutional +<span class="pagenum">Page 143<a name="Page_143" id="Page_143"></a></span> +effects of even trivial local infections are apt to be +disproportionately great.</p> + +<p>Fatigue is easily induced and is exhibited in all varieties of +activity—mental, physical, or visceral. Mental work may produce +fatigue with extreme readiness even although the quality of the work +may remain of a high standard. To Darwin and to Zola work for more +than three hours daily was an impossibility, and yet their work done +under these restrictions excites all men's admiration. The palpitation +and breathlessness which follows upon trivial exertion, such as +climbing a flight of stairs, is a good example of visceral fatigue.</p> + +<p>Among adult neuropaths we recognise the harm which may be done by +unwise speeches on the part of relatives, or still more on the part of +doctors. A chance word from a doctor or nurse off their guard for the +moment will implant in the minds of many such a person the unyielding +conviction that he or she is suffering from some gastric complaint, +from some cardiac affection, or from some constriction of the bowel. +It may take the united force of many doctors to uproot this +pathological doubt which was implanted so easily and so carelessly. +The medical student is notoriously prone to recognise in himself the +symptoms of ailments which he hears discussed. Little children, too, +are apt to suffer in the same way. How much illness could be avoided +if mothers would cease to erect some single manifestation of +insufficient nervous control into a local disorder which becomes an +object of anxiety to the child and to the whole household.</p> + +<p><span class="pagenum">Page 144<a name="Page_144" id="Page_144"></a></span> +Undue liability to fatigue, irritability, instability, lack of +control over the emotions, extreme suggestibility, prompt and +exaggerated reactions to toxins of all sorts, excessive vasomotor +reactions and anomalies of secretion, weakness of the +gastro-intestinal apparatus—these, and many other symptoms, are of +everyday occurrence in the nervous child. To discuss them more fully +would be to pass too far from our nursery studies into a consideration +of psychological medicine.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 145<a name="Page_145" id="Page_145"></a></span></p> + +<h3>CHAPTER XI</h3> + +<h3>NERVOUSNESS AND PHYSIQUE</h3> +<p> </p> + +<p>It has already been said that symptoms of nervousness are often +accompanied by faults in the physical development of the child. The +defects may assume so many forms as to make any attempt at description +very difficult. Nevertheless, certain types of physical defect present +themselves with sufficient frequency, in combination with neurosis, to +merit a detailed description. For example, we recognise a type of +nervous child which is marked by a persistence into later childhood of +certain infantile characteristics of the build and shape of body. +Further, we meet with a group characterised by a special want of tone +in the skeletal muscles, by lordosis, by postural albuminuria, and by +abdominal and intestinal disturbances of various sorts. We recognise +also the rheumatic type of child with a tendency to chorea, and in +contrast to this a type with listlessness, immobility, and katatonia. +Lastly, in a few children, in boys as well as in girls, we may meet +with cases of hysteria.<a name="FNanchor_3_3" id="FNanchor_3_3" /><a href="#Footnote_3_3" class="fnanchor">[3]</a></p> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3" /><a href="#FNanchor_3_3"> +<span class="label">[3]</span></a> If we accept as hysterical all symptoms which are +produced by suggestion and which can be removed by suggestion, we may +correctly speak of a physiological hysteria of childhood, which +includes a very large number of the symptoms discussed. The term is +used here in its older more limited sense.</p></div> + +<p><span class="pagenum">Page 146<a name="Page_146" id="Page_146"></a></span></p> + +<p class="subhead">(1) A Group with Persistence of Certain Infantile Characteristics</p> + +<p>During the first year or eighteen months of life, the rounded +infantile shape of body persists. The limbs are short and thick, the +cheeks full and rounded, the thorax and pelvis are small, the abdomen +relatively large and full. The great adipose deposit in the +subcutaneous tissue serves as a depôt in which water is stored in +large amounts. In the healthy child of normal development by the end +of the second year a great change has taken place. The shape of the +body has become more like that of an adult in miniature. The limbs +have grown longer and slimmer. The thorax and pelvis have developed so +as to produce relatively a diminution in the size of the abdomen. The +body fat is still considerable, but no longer completely obliterates +the bony prominences of the skeleton. Delay in this change, in this +putting aside of the infantile habit of body, is commonly associated +with a corresponding backwardness in the mental development. Such +children walk late, talk late, learn late to feed themselves, to bite, +and to chew effectively. Watery and fat, they carry with them into +later childhood the infantile susceptibility to catarrhal infections +of the lung, bowel, skin, etc., and they are apt to suffer, in +consequence, from a succession of pyrexial attacks. Nasal catarrh, +bronchitis, otitis media, enteritis, eczema, urticaria papulata, are +apt to follow each other in turn, giving rise in many cases to a +persistent enlargement +<span class="pagenum">Page 147<a name="Page_147" id="Page_147"></a></span> +of the corresponding lymphatic glands. The +effect upon the different tissues of the body of these repeated +infections is very various. We are probably not wrong in attributing +the failure to develop and the persistently infantile appearance to a +prejudicial effect upon the various ductless glands in the body. The +condition is associated with an excessive retention of fluid in the +body, secondary in all probability to alterations in the concentration +and distribution of the saline constituents of the body. A rapid +excretion of salts may be followed by a correspondingly speedy +dehydration of the body, a retention of salts by a sudden increase of +weight. The parathyroid glands are probably closely concerned in +regulating the retention and excretion of salts, and especially of +calcium, a circumstance which becomes of significance when we remember +how frequently rickety changes, tetany, and other convulsive seizures +form part of the clinical picture which we are now considering. While +it is difficult to determine the effect of repeated infections upon +the functions of the endocrine glands, we have clear evidence of the +deleterious influence upon almost all the tissues of the body, the +functioning of which it is more easy to estimate. For example, the +cells of the skin and of the mucous membranes which happen to be +visible to the eye show clear evidence of diminished vitality and +increased vulnerability. Physiological stimuli, incapable of producing +any visible reaction in healthy children, habitually determine widely +spread and persistent inflammatory reactions. For example, +<span class="pagenum">Page 148<a name="Page_148" id="Page_148"></a></span> +the licking movements of the tongue at the corners of the mouth produce +the little unhealthy fissures which the French call <i>perlèche</i>. The +physiological stimulus of the erupting tooth is capable of causing a +painful irritation of the gum, so that the child is said to suffer +from teething, accompanied, it may be, and the association is +significant, by "teething convulsions." The irritation of the urine +produces rawness and excoriation of the skin of the prepuce, contact +with intestinal contents not in themselves very abnormal, an +intractable dermatitis of the buttocks or a persistent diarrhoea and +enteral catarrh. Improvement in the general health, the result of the +cessation for the time being of the recurrent infections, perhaps +consequent upon improved hygienic conditions, always determines the +rapid disappearance of all these accompaniments of the general +diminution of tissue vitality.</p> + +<p>The muscular system and the bones are commonly also involved, so that +rickety changes are often found in these infantile and watery +children. In early childhood the processes of calcification and +decalcification proceed side by side and with great rapidity, and in +health there is always a balance on the side of the constructive +process. In the children whom we are now considering, saturated as +they are, from time to time, with the toxins resulting from repeated +infection, ossification may be so interfered with as to cause +softening and bending, with the evolution of a state of rickets. +Between bone and muscle, too, we find a close relationship. We do not +find powerful muscles with softened bone, +<span class="pagenum">Page 149<a name="Page_149" id="Page_149"></a></span> +nor flabby muscle with rigid and well-formed bone.</p> + +<p>In the nervous system, the conditions are somewhat different. In skin, +in bone, and in muscle new cell elements are constantly being formed, +and the life of the individual cell is relatively short. In the +nervous system, on the other hand, the individual cells are long +lived. Their life-history may even be coterminous with that of the +individual, and if destroyed they are not replaced. Nevertheless, they +do not escape undamaged in the general disturbance. In a deprivation +of calcium we have, in all probability, the explanation of the +increased irritability of peripheral nerves and of the tendency to +convulsive seizures of all sorts which is a common accompaniment of +the condition. Convulsions, laryngismus stridulus, tetany, or +carpopedal spasm are all frequently met with. In crying, the children +hold their breath to the point of producing extreme cyanosis, ending, +as the spasm relaxes, with a crowing inspiration, which resembles and +yet differs in tone from both the whoop of whooping-cough and the +crowing inspiration of croup.</p> + +<p>Apart, however, from this tendency to convulsive seizures the nervous +system of these children is abnormal. As a rule they are excitable, +and develop late the power to control their emotions. Lagging behind +in physical development and in the capacity to interest themselves in +the pursuits of normal children, their emotional state remains that of +a much younger child. In the infant classes at schools they are +recognised as dullards, learning +<span class="pagenum">Page 150<a name="Page_150" id="Page_150"></a></span> +slowly, speaking badly, and lacking co-ordination in all muscular movements.</p> + +<p>The clinical picture so depicted is encountered with extreme frequency +among the children of the poor in our large cities. To find a name for +the condition is no easy matter. To call it "rickets" is to place an +undue emphasis upon the bony changes which, though common, are by no +means invariable. Elsewhere I have suggested the name status +catarrhalis, on an analogy with the name status lymphaticus, which in +the post-mortem room is used to describe the secondary overgrowth of +lymphatic tissue which is found in these catarrhal children. In the +present connection it is of interest to us to note how commonly the +nervous system is involved in the general picture and the frequency +both of convulsive disorders and of neuropathy.</p> + +<p>The nervous symptoms of both sorts are to be allayed only by improving +the general hygiene of the child and raising its resistance against +infection. A sufficiency of fresh air and of sunlight, and a +management which encourages independence of action in the child, are +both necessary. The diet is of the first importance. It should be +sufficient, and no more than sufficient, to cover the physiological +needs of the child for food. The majority of these children have +enormous appetites, and excess of food, and especially of carbohydrate +food, plays some part in the production of the disturbance. We must +guard against overfeeding, against want of air and want of exercise, +and against those errors of management described in previous chapters, which +<span class="pagenum">Page 151<a name="Page_151" id="Page_151"></a></span> +produce the maximum of disturbance in this type of child.</p> + + +<p class="subhead">(2) A Group with Muscular Atrophy, Lordosis, and Postural Albuminuria</p> + +<p>At an older age, in children from the fifth year onwards, a second +type of physical defect associated with pronounced nervous disturbance +presents itself with some frequency. The body is thin and badly +nourished, and the muscular system especially poorly developed and +very lax in tone. The most striking feature is the extreme lordosis, +accompanied usually by a secondary and compensatory curve in the +cervico-dorsal region, so that the shoulders are rounded, with the +head poked forward. Viewed from in front the abdomen is seen to be +prominent, overhanging the symphysis pubis, while the shoulders have +receded far backwards. The scapulæ have been dragged apart, as though +by the weight of the dependent arms, with eversion of their vertebral +borders and lowering of the points of the shoulders. The position +which they adopt is that into which the body falls when it ceases to +be braced by strong muscular support. The muscular system is here so +weakly developed and so toneless that the posture is determined by the +bony structure and its ligamentous attachments.</p> + +<p>The lordosis resembles the similar deformity which develops in cases +of primary myopathy, when the spinal muscles have undergone complete +atrophy. As in myopathy the movements are +<span class="pagenum">Page 152<a name="Page_152" id="Page_152"></a></span> +very uncertain. The children are apt to fall heavily when the centre of gravity is +suddenly displaced, because their upright posture is maintained by +balancing the trunk upon the support of the pelvis. The frequency and +severity of the falls which these children suffer is a common +complaint of the mother. The faulty posture is often associated with +slight albuminuria. Its appearance is very capricious, but it is +dependent to a great extent upon the assumption of the erect posture. +There has been much discussion as to its explanation. It has been +argued that the lordosis itself produces the albuminuria by mechanical +compression of the renal vein, and it is said that albuminuria can be +produced, even in the prone position, by placing the child in a +plaster jacket applied so as to maintain the position of lordosis. +Other observers, however, have not obtained this result. It seems most +likely that the albuminuria is due to defective tone in the vasomotor +musculature, comparable in every way to the defective tone in the +muscles of the skeleton. We have often further evidence of vasomotor +weakness. Fainting attacks are so common as to be the rule rather than +the exception. Again, mothers are likely to complain of the child's +pallor and of dark lines under the eyes, especially after exertion or +in the reaction which follows excitement of any sort. As a rule a +blood count will not show any very striking evidence of true anæmia. +The pallor is of vasomotor origin, determined by faults in the +distribution of the blood from vasomotor weakness and not by deficient +<span class="pagenum">Page 153<a name="Page_153" id="Page_153"></a></span> +blood formation. Circulatory and vasomotor disturbance probably also +accounts for the dyspeptic pains and vomiting which commonly accompany +any emotional excitement, or follow any unusual exertion or fatiguing +experience. Constipation is a common, and mucous diarrhoea an +occasional, symptom. The abdomen is often pigmented. The hands and +feet are usually cold and cyanosed.</p> + +<p>The extreme nervousness of the children is the point upon which most +stress may be laid in the present connection. The association of +albuminuria with neurosis in childhood has been noticed by many +observers. The gastric and intestinal symptoms are especially +characteristic. If the condition of the children is not materially +improved, and if the symptoms, both of the physical defect and of the +nervous disturbance, are not cut short, we may predict that in adult +age their lives will be made miserable by a variety of abdominal +symptoms dependent both on the vasomotor disturbance and upon the +accompanying neurosis. Now that surgery forms so large a part of our +therapeutic proceedings, they may not reach middle life without being +submitted to one or more surgical operations. With good management +both on the physical side and on the moral or psychological side they +can be made into strong and useful members of society.</p> + +<p>The treatment of these cases may be summed up as follows:</p> + +<p><i>(a)</i> We must search for any source of infection, a source which is +often to be found in the condition +<span class="pagenum">Page 154<a name="Page_154" id="Page_154"></a></span> +of the tonsils. Enucleation may then be indicated as the first step in treatment.</p> + +<p><i>(b)</i> Massage and gymnastic exercises calculated to improve the +muscular tone, while every effort is made to secure for the child as +perfect hygiene in the environment as possible.</p> + +<p><i>(c)</i> The stimulating effect of cold douches is often very evident in +improving the vasomotor tone. These children, however, will not stand +well the abstraction of heat from their thin and chilly little bodies, +so that it is a good plan before the colder douche to immerse the +child in a hot bath and to return again to the bath momentarily +afterwards. With these precautions children will often enjoy a cold +spray, the temperature of which may be constantly lowered as they +become used to it. Prolonged hot bathing has a correspondingly +prejudicial effect.</p> + +<p><i>(d)</i> We must be on the watch to prevent the development of further +postural deformities, such as scoliosis. If a child of strong muscular +tone and good physique habitually adopts some posture, curled up, it +may be, in some favourite easy-chair, there is little likelihood that +its constant assumption will produce deformity. When the muscular +system is lax and weak, on the other hand, deformity such as scoliosis +is very readily caused. It is important, for example, to see that the +child does not habitually incline to one side in reading or writing. +When there is little energy for free and energetic play the children +are apt to become great bookworms. If there is shortsightedness, the +dangers are correspondingly +<span class="pagenum">Page 155<a name="Page_155" id="Page_155"></a></span> +increased. A special chair may be made +with a well-fitting back and the seat a little tilted upwards so as to +throw the child's trunk on to the support of the back. Lastly, a desk, +the height of which can be regulated at will, can be swung into the +proper position. The child, sitting straight and square, with the +weight supported by the foot-rest and back as well as by the seat of +the chair, should be taught to write with an upright hand, avoiding +the slope which leads to sitting sideways with the left shoulder +lowered.</p> + +<p>(e) Malt extract, cod liver oil, Parrish's food, and other tonics may +be of undoubted service.</p> + + +<p class="subhead">(3) Rheumatism and Cholera</p> + +<p>It is certain that there is a close association between rheumatism in +childhood and the common nervous affection known as chorea. We are +still ignorant of the precise nature of the infection which we know as +rheumatism. There is much to suggest that in rheumatism we have to +deal only with a further stage in those catarrhal infections to which +so much infantile ill-health is to be attributed, and that +endocarditis and arthritis, when they arise, signalise the entry of +these catarrhal, non-pyogenic organisms into the blood stream, +overcoming at last the barrier of lymphoid tissue which has +hypertrophied to oppose their passage. Certainly the connection of +rheumatism with catarrhal infections of the mucous membranes and +adenoid enlargements +<span class="pagenum">Page 156<a name="Page_156" id="Page_156"></a></span> +of all sorts is a close one. Whatever its +nature, the rheumatic infection in childhood is more lasting and +chronic than in adult life. Rheumatism in childhood is not manifested +by acute and short-lived attacks of great severity so much as by a +long-continued succession of symptoms of a subacute nature, a +transient arthritis, perhaps, succeeding an attack of sore throat with +torticollis, to be followed by carditis, to be followed again by +another attack of tonsillitis. And so the cycle of symptoms revolves. +In most cases the child grows thin and weak; in most cases he becomes +restless, irritable, and unhappy; often there is definite chorea. Of +this cerebral irritability chorea is the expression. In adults, chorea +is perhaps more obviously associated with mental stress of all sorts +and with states of excitement and agitation. In the case of little +children it is often only the mother who really appreciates how +radical an alteration the child's whole nature has undergone, and how +great the element of nervous overstrain has been before the chorea has +appeared.</p> + +<p>Of the treatment of chorea there is no need to speak. It is purely +symptomatic. Isolation, best perhaps away from home, as might be +expected, gives the best results. If there are pronounced rheumatic +symptoms, the salicylates will be needed; if there is anæmia, arsenic +and iron; if there is sleeplessness and great restlessness, bromides +or chloral. Hypnotism is often almost instantly successful, but, apart +from hypnosis, curative suggestions +<span class="pagenum">Page 157<a name="Page_157" id="Page_157"></a></span> +proceeding from the attendants +form the principal means at our disposal.</p> + + +<p class="subhead">(4) Exhaustion and Katatonia</p> + +<p>A large number of children, in convalescence from infective disorders, +when the nutrition of the body has fallen to a low ebb, show as +evidence of cerebral exhaustion a group of symptoms which in a sense +are the reverse of those which characterise cerebral irritation and +chorea. The healthy child is a creature of free movement. The children +we are now considering will sit for a long time motionless. The +expression of their faces is fixed, immobile, and melancholy. If the +arm or leg is raised it will be held thus outstretched without any +attempt to restore it to a more natural position of rest for minutes +at a time. The posture and expression remind us at once of the +katatonia which is symptomatic of dementia præcox and other stuporose +and melancholiac conditions in adult life. Symptoms of this sort are +especially common in children with intestinal and alimentary +disturbances of great chronicity.</p> + +<p>The symptom is so frequently met with that it is strange that it +should have attracted so little attention as compared with the +contrasting condition of chorea. And yet it is of more serious +significance, more difficult to overcome, and with a greater danger +that permanent symptoms of neurasthenia will result. In early +childhood a careful dietetic régime, suitable hygienic surroundings, +and a stimulating +<span class="pagenum">Page 158<a name="Page_158" id="Page_158"></a></span> +psychical atmosphere will often effect great +improvement. As in chorea, however, relapses are frequent, and there +are cases which for some unexplained reason are peculiarly resistant +to all remedial influences.</p> + + +<p class="subhead">(5) Hysteria</p> + +<p>In hysteria, in contrast to the types previously described, the +infective element may be completely absent. Except in some special +features of minor importance the symptoms of hysteria do not differ +from those of adults, and, as in adult age, the condition of hysteria +may be present although the physical development may be perfect. We +cannot here speak of any physical characteristics which are associated +with the nervous symptoms.</p> + +<p>The third or fourth year represents the age limit, below which +hysterical symptoms do not appear. Thereafter they may be occasionally +met with, with increasing frequency. At first, in the earlier years of +childhood, there is no preponderance in the female sex. As puberty +approaches, girls suffer more than boys.</p> + +<p>It may be said to be characteristic of hysteria in childhood that its +symptoms are less complex and varied than in adult life. The naive +imagination of the child is content with some single symptom, and is +less apt to meet the physician half-way when he looks for the +so-called stigmata. Similarly mono-symptomatic hysteria is +characteristic of oases occurring in the uneducated or peasant class. +<span class="pagenum">Page 159<a name="Page_159" id="Page_159"></a></span> +In children, hysterical pain, hysterical contractures or palsies, +mutism, and aphonia are the most usual symptoms. Hysterical deafness, +blindness, and dysphagia are manifestations of great rarity in +childhood.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 160<a name="Page_160" id="Page_160"></a></span></p> + +<h3>CHAPTER XII</h3> + +<h3>THE NERVOUS CHILD IN SICKNESS</h3> +<p> </p> + +<p>In time of sickness the management of the nervous child becomes very +difficult. Restlessness and opposition may reach such a pitch that it +may be almost impossible to confine the patient to bed or to carry out +the simplest treatment. Sometimes days may elapse before the +sick-nurse who is installed to take the place of the child's usual +attendant is able to approach the cot or do any service to the child +without provoking a paroxysm of screaming. In such a case any +systematic examination is often out of the question, with the result +that the diagnosis may be delayed or rendered impossible. There is +only one reassuring feature of a situation, which arises only in +nurseries in which the management of the children is at fault; the +doctor has learned from experience that this pronounced opposition of +the child to himself, to the nurse, and even to the mother, is of +itself a reassuring sign, indicating, as a rule, that the condition is +not one of grave danger or extreme severity. When the child is more +seriously ill, opposition almost always disappears, and the child lies +before us limp and +<span class="pagenum">Page 161<a name="Page_161" id="Page_161"></a></span> +passive. Only with approaching recovery or +convalescence does his spirit return and renewed opposition show +itself.</p> + +<p>Extreme nervousness in childhood carries with it a certain liability +towards what is known as "delicacy of constitution." The sensitiveness +of the children is so great that they react with striking symptoms to +disturbances so trivial that they would hardly incommode the child of +more stable nervous constitution. For example, a simple cold in the +head, or a sore throat, may cause a convulsion or a condition of +nervous irritability which may even arouse the suspicion that +meningitis is present. Or, again, a little pharyngeal irritation which +would ordinarily be incapable of disturbing sleep may be sufficient to +keep the child wide awake all night with persistent and violent +coughing. The little irritating papules of nettlerash from which many +children suffer are commonly disregarded by busy, happy children +during the day, and even at night hardly suffice to cause disturbance. +The nervous child, on the other hand, will scratch them again and +again till they bleed, tearing at them with his nails, and making deep +and painful sores.</p> + +<p>The temperature is commonly unstable and readily elevated. Moreover, +feverishness from whatever cause is often accompanied by an active +delirium, which is apt to occasion unnecessary alarm. This symptom of +delirium is always a manifestation of an excitable temperament. I +remember being called to see a young woman who +<span class="pagenum">Page 162<a name="Page_162" id="Page_162"></a></span> +was thought to be suffering from acute mania. +Examination showed that she was suffering +from pneumonia in the early stages. It was only later that we +discovered that she had always been of an unstable nervous +temperament, and had been in an asylum some years before. Those of us +who are fortunate in possessing a placid temperament and have +developed a high degree of self-control are not likely to show +delirium as a prominent symptom should we fall ill with fever; just as +we should not struggle and scream too violently when we "come round" +from having gas at the dentist's. Looked at from this point of view, +it is natural for all children to become delirious readily, and this +tendency is peculiarly marked in those who are unduly nervous.</p> + +<p>As a consequence of this extreme sensitiveness, the nervous child is +likely to suffer more than others from a succession of comparatively +trifling ailments and disturbances. The delicacy of the child has, in +this sense, a real existence, and is not confined to the imagination +of over-anxious and apprehensive parents. No doubt the nervous mother +of an only child does worry unnecessarily, and is far too prone to +feed her fears by the daily use of the thermometer or the +weighing-machine; but her friends who are happy in the possession of +numerous and placid children are not justified in laying the whole +blame upon her too great solicitude. Children who are members of large +families, whose nervous systems have been strengthened by contact with +their brothers and sisters, are not habitually +<span class="pagenum">Page 163<a name="Page_163" id="Page_163"></a></span> +upset by trifles, and suffer even serious illnesses with symptoms of less severity. +Nervous children, and only children, on the other hand, show the opposite +extreme. Nevertheless, the mother of a nervous and delicate child—a +child, that is to say, who, even if he is not permanently an invalid, +nevertheless never seems quite well and lacks the robustness of other +children—should realise clearly how much of this sensitiveness is due +to the atmosphere of unrest and too great solicitude which surrounds +him. It is a matter of universal experience that excess of care for +only children has a depressing influence which affects their +character, their physical constitution, and their entire vitality. At +all costs we must hide our own anxieties from the child, and we must +treat his illnesses in as matter-of-fact a way as possible.</p> + +<p>When illness comes, his daily routine should be interrupted as little +as possible. In dealing with nervous children, it is often better to +lay aside treatment altogether rather than to carry out a variety of +therapeutic procedures which have the effect of concentrating the +child's mind upon his symptoms. When we grown-up people are sick, we +often find a great deal of comfort in submitting ourselves to some +form of treatment. We have great faith, we say, in this remedy or in +that. It is <i>our</i> remedy, a <i>nostrum</i>. The physician knows well that +the opportunities which are presented to him of intervening +effectually to cut short the processes of disease by the use of +specific cures are not very numerous, and that often enough the +justification +<span class="pagenum">Page 164<a name="Page_164" id="Page_164"></a></span> +for his prescription is the soothing effect which it +may exercise upon the mind of the patient, who, believing either in +the physician or in his remedy, finds confidence and patience till +recovery ensues. As a rule this form of consolation is denied to +little children. They have no belief in the efficacy of the remedies +which are applied with such vigour and persistence. Indeed, it is not +the child, but his anxious mother, who finds comfort in the thought +that everything possible has been done. Therefore, a prescription must +be written and changed almost daily, the child's chest must be +anointed with oil, and the air of the sick-room made heavy with some +aromatic substance for inhalation, and all this when the disturbance +is of itself unimportant, and owes its severity only to the undue +sensitiveness of the child's nervous system.</p> + +<p>The very name of illness should be banished from such nurseries. +Everything should be done to reassure the child and to make light of +his symptoms, and we can keep the most scrupulous watch over his +health without allowing him to perceive at all that our eye is on him. +With older children the evil results of suggestions, unconsciously +conveyed to them by the apprehension of their parents, become very +obvious. The visit of the doctor, to whom in the child's hearing all +the symptoms are related, is often followed by an aggravation which is +apt to be attributed to his well-meant prescription. The harm done by +examinations, which are specially calculated to appeal to the child's +imagination, as, for instance, an X-ray examination, +<span class="pagenum">Page 165<a name="Page_165" id="Page_165"></a></span> +is often clearly apparent. I remember a schoolboy of thirteen who was sent to me +because he had constantly complained of severe abdominal pain. He was +a nervous child with a habit spasm, the son of a highly neurotic +father and an overanxious mother. An X-ray examination was made, but +showed nothing amiss. The child's interest and preoccupation in the +examination was painfully obvious. That night his restraint broke down +altogether, and he screamed with pain, declaring that it had become +insupportable. Younger children, less imaginative but equally +perverse, noticing how anxiously their mothers view their symptoms, +will often make complaint merely to attract attention and to excite +expressions of pity or condolence. Sometimes they will enforce their +will by an appeal to their symptoms. I have had a little patient of no +more than thirteen months of age who suffered severely and for a long +time from eczema, and who in this way used his affliction to ensure +that he got his own way. If he was not given what he wanted +immediately he would fall to scratching, with an expression upon his +face which could not be mistaken. To him, poor child, the grown-up +people around seemed possessed of but one desire—to stop his +scratching; and he had learnt that if he showed himself determined to +scratch they would give way on every other point.</p> + +<p>The ill-effects of departing too readily from ordinary nursery routine +on account of a little illness, and of adopting straightway a variety +of measures of treatment, is well shown in cases of +<span class="pagenum">Page 166<a name="Page_166" id="Page_166"></a></span> +asthma in children. The asthmatic child is almost always of a highly nervous +temperament, and often passionate and ungovernable. Often the most +effective treatment of an attack, which usually comes on some hours +after going to bed, is to make little of it, to talk naturally and +calmly to the child, to turn on the light, and to allow him, if he +will, to busy himself with toys or books. To be seized with panic, to +send post-haste for the doctor, to carry the patient to the open +window, to burn strong-smelling vapours, and so forth, not only is apt +to prolong the nervous spasm on this occasion, but makes it likely +that a strong impression will be left in his mind which by +auto-suggestion will provoke another attack shortly. With nervous +children a seeming neglect is the best treatment of all trivial +disorders. Meanwhile we can redouble our efforts to remedy defects in +management, and to obtain an environment which will gradually lower +the heightened nervous irritability.</p> + +<p>When the illness is of a more serious nature, as has been said, the +restlessness as a rule promptly disappears. In each case it must be +decided whether it is best for the child to be nursed by his mother +and his own nurse, or by a sick-nurse. In the latter event the +ordinary nurse and the mother should absent themselves from the +sick-room as much as possible. Often the firm routine of the hospital +nurse is all that is wanted to obtain rest. Less often, the child will +be quiet with his own nurse, and quite unmanageable with a stranger.</p> + +<p>There is, however, another side to the question. +<span class="pagenum">Page 167<a name="Page_167" id="Page_167"></a></span> +The relation of neurosis in childhood to infection of the body is complex. +I have said that with the nervous child a trivial infection may produce symptoms +disproportionately severe. Persistent and serious infection, however, +is capable of producing nervous symptoms even in children who were not +before nervous, and we must recognise that prolonged infection makes a +favourable soil for neuroses of all sorts. The frequency with which +St. Vitus's dance accompanies rheumatism in childhood forms a good +example of this tendency. The child who, from time to time, complains +of the transient joint pains which are called "growing pains," and who +is found by the doctor to be suffering from subacute rheumatism, is +commonly restless, fretful, and nervous. Appetite, memory, and the +power of sustained attention become impaired. Often there is excessive +emotional display, with, perhaps, unexplained bursts of weeping. The +child is readily frightened, and when sooner or later the restless, +jerky movements of St. Vitus's dance appear, the usual explanation is +that some shock has been experienced, that the child has seen a street +accident, has been alarmed by a big dog jumping on her, or by a man +who followed her—shocks which would have been incapable of causing +disturbance, and which would have passed almost unappreciated had not +the soil been prepared by the persistent rheumatic infection.</p> + +<p>The management of the nervous child whose physical health remains +comparatively good is difficult enough, but these difficulties are increased +<span class="pagenum">Page 168<a name="Page_168" id="Page_168"></a></span> +many times when the physical health seriously fails. To +steer a steady course which shall avoid neglecting what is dangerous +if neglected, and overemphasising what is dangerous if +over-emphasised, calls for a great deal of wisdom on the part both of +the mother and her doctor.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 169<a name="Page_169" id="Page_169"></a></span></p> +<h3>CHAPTER XIII</h3> + +<h3>NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS</h3> +<p> </p> + +<p>In this chapter I approach with diffidence a subject which is rightly +enough occupying a great deal of attention at the present time: the +instruction of our children in the nature, meaning, and purpose of +sexual processes. It is a subject filled with difficulties. Every +parent would wish to avoid offending the sense of modesty which is the +possession of every well-trained child, and finds it difficult to +escape the feeling that discussion on such matters may do more harm +than good. There is certainly some risk at the present time that, +putting reticence on one side, we may be carried too far in the +opposite direction. The evils which result from keeping children in +ignorance are well appreciated. We have yet to determine the effect +upon them of the very frank and free exposure of the subject which is +recommended by many modern writers. Nevertheless, it must be granted +that it is not right to allow the boy or girl to approach adolescence +without some knowledge of sex and the processes of reproduction. If +nothing is said on such subjects, which in the nature of things are bound +<span class="pagenum">Page 170<a name="Page_170" id="Page_170"></a></span> +to excite a lively interest and curiosity in the minds of older +children, evil results are apt to follow. Because parents have never +mentioned these subjects to their child, they must not conclude that +he is ignorant of all knowledge concerning them. It is not unlikely +that the question has often occupied his thoughts, and that his +speculations have led him to conclusions which are, on the whole, +true, although perhaps incorrect in matters of detail. Most children, +unable to ask their mother or father direct questions upon matters +which they feel instinctively are taboo, have pieced together, from +their reading and observation, a faulty theory of sexual life. The +pursuit of such knowledge, in secret, is not a healthy occupation for +the child. His parents' silence has given him the feeling that the +unexplored land is forbidden ground. In satisfying his curiosity he is +most certainly fulfilling an uncontrollable impulse, but he has been +forced to be secretive, and to look upon the information he has +acquired as a guilty secret. So far even the best of children will go +upon, the dangerous path. If training has been good, and if the child +has responded well to it, he will go no further. Though he can hardly +be expected to refrain from constructing theories and from testing +them in the light of any chance information which may come his way, he +will instinctively feel that the subject is one best left alone. He +will not talk of it with other boys—not even with those who are older +than himself and whose superior knowledge in all other matters he is +accustomed to respect. +<span class="pagenum">Page 171<a name="Page_171" id="Page_171"></a></span> +We need not be surprised, however, that the +majority of children do not attain to this high standard of conduct, +and that the interest and excitement of exploring the unknown and the +forbidden proves too great. Children will consult with each other +about such matters, and knowledge of evil may spread rapidly from the +older to the younger. In some schools, as is well known, there may +grow up with deplorable facility an unhealthy interest in sexual +matters. On the surface of school life all may seem fair enough, but +beneath, hidden from all recognised authority, lies much that is +unspeakable. If the boy has not been taught to have clean thoughts +upon matters which are essentially clean, if he has not learned to +know evil that he may avoid it, he may not escape great harm. The +fault in us which kept him in ignorance will recoil upon our own +heads. He will maintain the barrier which was erected in the first +place by our own unhappy reticence, and we may find it a hard task to +penetrate behind it and prevent his constant return to secret thoughts +and imaginings or secret habits and practices. Certain physiological +processes come to have for him an unclean flavour which is yet +perniciously attractive. He knows little of the real meaning of sexual +processes or of the great purpose for which they are designed. It is +only that an unhealthy interest becomes attached to all subjects which +are scrupulously avoided in general conversation. In secret he +develops a wrong attitude to all these matters.</p> + +<p><span class="pagenum">Page 172<a name="Page_172" id="Page_172"></a></span> +Oliver Wendell Holmes<a name="FNanchor_4_4" id="FNanchor_4_4" /> +<a href="#Footnote_4_4" class="fnanchor">[4]</a> tells us that in religion certain words and +ideas become "polarised," that is to say, charged with forces of +powerful suggestion, and must be "depolarised."</p> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4" /><a href="#FNanchor_4_4"> +<span class="label">[4]</span></a> <i>The Professor at the Breakfast Table</i>, Oliver Wendell +Holmes.</p></div> + +<hr style="width: 45%;" /> + +<p>"I don't know what you mean by 'depolarising' an idea, said the +divinity-student.</p> + +<p>"I will tell you, I said. When a given symbol which represents a +thought has lain for a certain length of time in the mind, it +undergoes a change like that which rest in a certain position gives to +iron. It becomes magnetic in its relations—it is traversed by strange +forces which did not belong to it. The word, and consequently the idea +it represents, is polarised.</p> + +<p>"The religious currency of mankind, in thought, in speech, and in +print, consists entirely of polarised words. Borrow one of these from +another language and religion, and you will find it leaves all its +magnetism behind it. Take that famous word, O'm, of the Hindoo +mythology. Even a priest cannot pronounce it without sin; and a holy +Pundit would shut his ears and run away from you in horror, if you +should say it aloud. What do you care for O'm? If you wanted to get +the Pundit to look at his religion fairly, you must first depolarise +this and all similar words for him. The argument for and against new +translations of the Bible really turns on this. Scepticism is afraid +to trust its truths in depolarised words, and so cries out against a +new translation. I think, myself, if every idea +<span class="pagenum">Page 173<a name="Page_173" id="Page_173"></a></span> +our Book contains could be shelled out of its old symbol and put into a new, +clean, unmagnetic word, we should have some chance of reading it as +philosophers, or wisdom-lovers, ought to read it—which we do not and +cannot now, any more than a Hindoo can read the 'Gayatri' as a fair +man and lover of truth should do."</p> + +<hr style="width: 45%;" /> + +<p>Now in the minds of many boys and some girls certain words and ideas +connected with certain physiological processes become polarised. It is +the parents' duty to depolarise them. It is a task which cannot well +be deputed to others; nor can much help be derived from books, though +many have been written with the object of initiating children into the +mysteries of sex. No one but a parent is likely to be on sufficiently +intimate terms with the child to enable the subject to be approached +without restraint or awkwardness, and no book can adapt itself to the +varying needs of individual children. An exposition in cold print, or +a single formal lecture on the subject, is apt to do more harm than +good. I have seen instructions to parents to deliver themselves of set +speeches, examples of which are given, which seem to me well +calculated to repel and frighten the nervous child. Still more +dangerous is the advice to make sexual hygiene a subject for class +study. The task requires that parents should be upon very intimate +terms with their children, and on suitable occasions, when this +feeling of intimacy is strong, children should be encouraged to speak +freely and to ask for explanations. +<span class="pagenum">Page 174<a name="Page_174" id="Page_174"></a></span> +By a judicious use of such opportunities piece by piece the whole may be unfolded. +In order that the child may approach the subject in the proper spirit we may +stimulate interest by a few lessons in Natural History. A child of +eight or ten years of age is not too young to learn a little of the +outlines of anatomy and physiology. If he is told a few bald facts +about the skeleton, about the circulation and the processes of +digestion such as any parent can teach at the cost of a few hours' +study of a handbook, this will lead naturally enough, in later +lessons, to a similar talk upon the excretory organs, reproduction, +and the anatomy and processes of sex, suitable to the individual. To +achieve "depolarisation," there is nothing more efficacious than the +frankness and explicitness of scientific statement, however +elementary. Later a little knowledge of Botany and Zoology will enable +a parent to sketch briefly the outlines of fertilisation and +reproduction. The child may grasp the conception that the life of all +individual plants and animals is directed towards the single aim of +continuing the species. He can be told how the bee carries the male +pollen to the female flower, how all living things habitually +conjugate, the lowest in the scale of development as well as the +highest, and how the fertilised egg becomes the embryo which is +hatched by the mother or born of her. As the child grows older and +understands more and more of these natural processes an opportunity +can be used to make the presentation of the subject more personal. He +can be told that during childhood his own sexual +<span class="pagenum">Page 175<a name="Page_175" id="Page_175"></a></span> +processes have been +undeveloped, but that as he grows older they will awake. That with +their awakening in adolescence new temptations to self-indulgence in +thought or action may assail him, but that these temptations are +delayed by the wisdom of Nature until his understanding has grown and +his man's strength of character has developed. A high ideal of purity +should be set before boy and girl alike, and the conception of sex +from the beginning should be associated in their minds with the high +purpose to which some day it may be put. Before the boy goes to a +boarding-school he should have imbibed from his father the desire for +moral cleanliness, the knowledge of good and of evil, and a cordial +dislike for everything that is sensual, self-indulgent, or nasty. +Talks on such subjects should be very infrequent, but I believe that, +if "depolarisation" is to be achieved, they must be repeated every now +and then during later childhood and in adolescence. To attempt to +impart all this interesting information in a single constrained and +awkward interview is to court failure, or at least to run the risk +that the explanation is not fully understood, so that the child is +mystified, or even offended in his sense of propriety.</p> + +<p>I have dwelt at some length upon this question of sex education, +because it is one of especial difficulty when we have to deal with a +child of nervous inheritance, or with a child in whom symptoms of +neurosis have developed in a faulty home environment. Misconduct in +sexual matters is a sign of deficient nervous and moral control, and when the +<span class="pagenum">Page 176<a name="Page_176" id="Page_176"></a></span> +conduct in other respects is ill-regulated, the development +of sexual processes must be watched with some anxiety. There are those +who see a still more intimate relationship between errors of conduct +or symptoms of neurosis in childhood and the sexual instincts.</p> + +<p>It is perhaps necessary here briefly to refer to the teaching of +Sigmund Freud of Vienna, because his views have attracted a great deal +of attention in this country and have become familiar to a great part +of the reading public. Freud believes that the origin of many abnormal +mental states and of the disturbances of conduct which are dependent +upon them is to be traced back to forgotten experiences, the +recollection of which has faded from the conscious mind, but which are +still capable of exerting an indirect influence. He regards the +process of forgetting, not as merely a passive fading of mental +impressions, but as an active process of repression, by which the +experience, and especially the unpleasant experience, is thrust and +kept out of consciousness. There thus arises a mental conflict between +the forces of repression and the forces which tend to obtrude the +recollection into consciousness, and at times the energy engendered in +this conflict escapes from the censorship of the repressing forces and +finds vent in the production of abnormal mental states or disorders of +conduct. Thus to take a simple example, a business man who has had a +trying day at the office, on returning home in the evening may succeed +in thrusting out of his consciousness the thought of his +disappointments and worries, +<span class="pagenum">Page 177<a name="Page_177" id="Page_177"></a></span> +yet the disturbance in his mind may show itself in quarrels with his wife +or complaints of the quality of the cooking at dinner.</p> + +<p>Freud has called attention to the part which the suppressed and +long-forgotten experiences of early childhood play in the production +of neuroses of all sorts at a later date, and he has laid especial +emphasis on sexual experiences as peculiarly fruitful causes of such +disturbances. Those who have embraced Freud's teaching have gone even +farther than he in this direction, and by psycho-analysis—that is to +say, by attempting in intimate conversation to arouse the dormant +memory and lay bare the buried complex, the suppression of which has +produced the conflict in the mind of the sufferer—will seldom fail to +discover the influence of sexual forces and sexual attractions which, +while capable of causing disorders of mind and of conduct, show +themselves only obscurely and indirectly, as, for example, in dreams +or in symbolic form.</p> + +<p>So far as the nervous disorders of children are concerned, much that +is written to-day upon the influence of repressed sexual experiences +may be dismissed as grotesque and untrue. The conclusions to which the +psycho-analyst is habitually led, and which he puts forward with such +confidence, can be convincing only to those who have replaced the +study of childhood by the study of the writings of Freud and his +school. Thus it is common enough to find a mother complaining that her +child of two or three years of age is bitterly jealous of the new baby +who has come to share with him his mother's love and attention. +<span class="pagenum">Page 178<a name="Page_178" id="Page_178"></a></span> +According to the views of Freud, we are to recognise in this jealousy +an exhibition of the sexual instincts of the older child, who scents a +possible rival for the affections of his mother. Even if we give to +the term sexual the widest possible meaning, it is difficult for a +close observer of children to detect any truth in this conclusion. The +behaviour of the older child to the newly born will be determined +mainly by the attitude adopted by the grown-up persons around him and +by the unconscious suggestions which his impressionable mind receives +from them. If the mother is fearful of what may happen, and refuses to +leave the children alone, she will find it hard to hide from the older +child her conviction that danger is to be apprehended from him. If +this suggestion acts upon his mind, and if the reputation that he is +jealous of the new baby becomes attached to him, he will assuredly not +fail to act up to it, and her daily conduct will appear to prove the +justness of his mother's apprehension. Fortunately, mothers are +commonly able to divest themselves of such fears as these. The older +child is brought freely to the baby to admire him, to bestow caresses +on him, and to speak to him in the very tones of his elders. In a few +days his reputation is established, that he is "so fond of the baby," +and to this reputation too he faithfully conforms. We have seen in an +earlier chapter that constantly and ostentatiously to oppose a child's +will is to produce a counter-opposition which because of its +persistence and vigour appears to have behind it the strongest +possible concentration of mind and power of will. +<span class="pagenum">Page 179<a name="Page_179" id="Page_179"></a></span> +Yet if we cease to oppose, the counter-opposition which appeared so formidable +at once dissolves, and the difficulty is at an end. We took as an example the +child's apparent determination to approach as near as possible to the +fire, the one place in the room which our fear of accident forbids +him. The difficulty with the new baby is but another example of the +same tendency. If he does not know that the ground is forbidden, if we +do not concentrate his attention on the prohibition, he will show no +particular desire to approach it. His apparent jealousy of his little +brother is the result not of the rivalry of sex, but of bad +management.</p> + +<p>Again, it is occasionally a subject of complaint that children will +apparently dislike their father, that they will shrink from him or +burst into tears whenever he approaches them. There is no need to see +in this the child's jealousy of the father as a rival in the +affections of his mother, which is the explanation proffered by the +school of Freud. Every action and every occupation of the child during +the whole day can be made a pleasure or a pain to him, according to +the attitude of his nurse and mother towards it. Eating and drinking +should be pleasant and are normally pleasant. The same forces which +are sufficient to make every meal-time a signal for struggling and +tears, are sufficient to produce this dislike, apparently so +invincible, to the father of his being.</p> + +<p>Although the nervous troubles of infancy are not commonly due, as +Freud and his numerous followers would have us believe, to suppressed +sexual desires +<span class="pagenum">Page 180<a name="Page_180" id="Page_180"></a></span> +or experiences, it is clear that in the sensitive mind +of the child the reception of a severe shock may have effects long +after the memory of it has disappeared from consciousness. In a +medical journal there was recently recounted the case of an officer of +the R.A.M.C. who all his life had suffered from claustrophobia—the +fear of being shut up in a closed space. By skilful questioning, the +remembrance of a terrifying incident in his childhood was regained. As +a child of five he had been shut in a passage in a strange house by +the accidental banging to of a door, unable to escape from the +attentions of a growling dog. A complete cure was said to follow upon +the discovery that in this incident lay the origin of the phobia. +Nevertheless, observation would lead me to lay the greater stress not +upon any one particular shocking or terrifying experience, but upon +the attitude of parents and nurses in focusing the child's attention +upon the danger, and in sapping his confidence by showing their own +apprehensions and communicating them to him.</p> + +<p>As a method of treatment for neuroses of childhood, psycho-analysis is +not only unsuccessful, it has dangers and produces ill effects which +far outweigh any advantage which may be gained from it.</p> + +<p>There can be no doubt that Freud has exaggerated the part which sexual +impulses play in causing neurosis. It will be sufficient for us to +recognise that for the nervous child the sexual life has especial +dangers, and we should redouble our efforts to +<span class="pagenum">Page 181<a name="Page_181" id="Page_181"></a></span> +prevent his ideas on the subject becoming "polarised." +For the child whose environment has been well regulated and who has developed +strength of character, self-control, and self-respect, there need be no fear.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 182<a name="Page_182" id="Page_182"></a></span></p> +<h3>CHAPTER XIV</h3> + +<h3>THE NERVOUS CHILD AND SCHOOL</h3> +<p> </p> + +<p>At the onset of puberty childhood comes to an end, and the period of +adolescence begins. Into these further stages of development it is not +proposed to enter, but it may be well to consider a question which is +apt to present itself for answer at this period: "Should the boy, or +girl, of nervous temperament, or whose development up to this point +has been accompanied by symptoms of nervous disorder, be sent to a +boarding-school?" So long as the child remains at home the home +environment is the force which alone is concerned in moulding his +character. We have seen how plastic the young child is, how imitative, +how suggestible, how prone to form habits good or bad. The diversity +of type shown by the homes is reflected in the diversity of character +and conduct exhibited by the children. The home is the culture medium, +and in no two homes is its composition the same. For each child home +influence remains to a great extent unchanged, and in great part +unchangeable. Its action upon the child is constant and long +sustained. Hence, it is not surprising that the growth of his +character and powers is +<span class="pagenum">Page 183<a name="Page_183" id="Page_183"></a></span> +commonly unequal. At one point we may find a +good crop of virtues, at another a barren tract; and the home +influences which have ripened the one and blighted the other are +calculated by the lapse of time to increase the contrast rather than +to diminish it.</p> + +<p>I suppose it is for this reason that the custom of sending children to +boarding-schools has so firm a hold among us. The boarding-school +forms an environment selected to correct the inequalities which result +from the special action upon the child of individual homes. The life +of a boy in one of our large public schools is well calculated to act +as a corrective in this way not only by reason of its ordered routine +and discipline, but still more because it is affected, perhaps for the +first time, by the strong force of public opinion. It is the strength +of this public opinion which gives to our public schools their +peculiar character and produces their peculiar effects. That which the +schoolboy most despises is what he calls "Bad Form," and he bows down +and worships an idol he himself has set up, the name of which is "Good +Form." Public opinion forms the code of morals observed in the school. +The standard set is commonly not so high as to be very difficult of +attainment. It demands many good qualities. To lie, to sneak, to tell +tales, to bully, to "put on side," are bad form. In some respects the +definition of what is virtuous may be a little hazy. Thus it may be +wrong to cheat to gain a prize, but to copy from one's neighbour only +so much as will enable one to pass muster and escape condemnation +<span class="pagenum">Page 184<a name="Page_184" id="Page_184"></a></span> +is no great sin. In short, good form demands that a boy should have all +the social virtues: that he should be a good fellow, easy to live +with, and possessed of a high sense of public spirit—good qualities +certainly, though perhaps not those which help to make the reformers +or martyrs of this world.</p> + +<p>The school life is the life of the herd, and to be successful in it +the boy must mingle with the herd, not break from it or shun it. Good +form—if we came to analyse the conception that underlies it—consists +only in a close approximation to the standard pattern; bad form, in +any deviation from it. It is this similarity of type and community of +ideals which makes it so easy for most public-school boys to get on +well with one another. When in after life they are thrown among a set +of men who know nothing of their conception of good form, and whose +training has been on completely different lines, there may be a +corresponding difficulty.</p> + +<p>Now what is true of public-school life is of course also true of the +larger life after schooldays are over for which all education is a +preparation. These qualities of sociability and good sportsmanship +will stand a man in good stead throughout life. Even the most ardent +and active spirit will benefit by being subjected for some years to +this steady pressure of public opinion. The most part will learn from +it good sense, consideration for others, and self-control. As they +pass from the lower forms to the higher in the school they will learn +too to support authority without doing injustice, and to bring the +<span class="pagenum">Page 185<a name="Page_185" id="Page_185"></a></span> +weight of public opinion to bear upon others. And to all this +training many a man owes his happiness in after life—a happiness +which he could not have secured if his character had been moulded only +by the environment of his home, or by the home in combination with the +less-powerful corrective of a day school. For the nervous child the +passage from home to school life may involve considerable mental +strain. He may be morbidly self-conscious and timid, or, unknown to +himself—because he has as yet no power of self-analysis and has no +opportunities of comparing himself with others—he may have developed +certain eccentricities. In most cases the plunge into school life will +be taken well enough; in a few the little vessel will not right +itself, and proves permanently unseaworthy. No doubt as a rule a +private school will have preceded the public school, and this +gradation should make the entrance to the public school a lesser +ordeal. But it often happens that it is just in the case of the +nervous child that this intermediate stage has been omitted, and that +his thirteenth birthday finds him still in the home circle.</p> + +<p>If the boy's father has first-hand knowledge of life in the lower +forms of public schools, his experience may enable him to form some +estimate of the effect of school life upon the nervous system of his +son. It is when parents or guardians have no such experience of their +own to guide them that mistakes are most liable to be made. I can +myself remember the unhappy state of some solitary and eccentric +schoolfellows of mine who aroused the +<span class="pagenum">Page 186<a name="Page_186" id="Page_186"></a></span> +resentment of "the Herd" by +their behaviour or opinions. If it is clear that the boy has a +peculiar temperament and is likely to suffer in this way, some <i>via +media</i> must be found. The home has failed so that he must leave home +and come under the influence of some one who understands the nature of +the difficulty and can adapt the boy to school life. A change of +environment of this sort as a preliminary to the public school is +often all that is needed. If his age permits, every effort should be +made in this way to obtain for the nervous child who has developed +peculiarities or faults the benefits of a public-school education.</p> + +<p>Some types of nervous children will show immediate improvement when +they go to school. The boy who is passionate and disobedient, and +whose parents cannot control him, is best at school. Boys who, from +being much with grown-up people, have become too precocious and have +acquired the habits and tastes of their elders, will dislike school at +first, but it will do them good. Their fault shows that they are quick +to learn and sensitive to the influences of others, and they will soon +adapt themselves to their new surroundings. Boys who are dreamy and +imaginative, who early adopt a "specialist" attitude towards life, +who, however ignorant they may be of everything else, cultivate a +reputation for omniscience in some particular subject, such as +Egyptology, astronomy, or the construction of battleships, are usually +nervous boys whose symptoms will disappear at school. Where undue +timidity, phobia, or habit spasm is +<span class="pagenum">Page 187<a name="Page_187" id="Page_187"></a></span> +present, the question is more +difficult to decide. Every individual case must be studied as a whole, +and our object should be not unnecessarily to deprive the boy of the +wholesome training of public-school life.</p> + +<p>There are parents who from sheer ignorance add to the difficulties +which the boy encounters in going to school. Failure to appreciate +very small points may cause unnecessary suffering. To be the only boy +in the school to wear combinations is not a distinction that any new +boy craves, however strong his nerves may be. A friend of mine still +relates with feeling how, twenty years ago, he arrived at school with +shirts which <i>buttoned</i> at the neck! At night when every one else in +the dormitory was asleep he sat for hours on his bed, miserable beyond +words, removing the buttons and doing his best in the dark to bore +buttonholes which would admit what every other boy in the school +had—a collar stud.</p> + +<p>With girls perhaps this question of fitness for school life does not +arise in so urgent a way. Girls are usually older when they go to +school, and girls' schools are perhaps less terrifying and more like +home. There is, however, one important point which should be borne in +mind. The date of the onset of puberty varies much in both sexes. If +the boy grows to a great hulking fellow at fourteen, and even displays +a desire secretly to borrow his father's razor, he is at no particular +disadvantage as compared with his fellows. He is so much bigger and +stronger than the others that he may +<span class="pagenum">Page 188<a name="Page_188" id="Page_188"></a></span> +thereby early enjoy the +distinction of playing at "big side," or of getting a place in the +school Eleven. He is probably much envied by those of the same age +who, with the aid of their youthful aspect, can still occasionally +extract compensation by inducing the railway company to let them +travel to school at half fare. But with girls it is different. Many at +fourteen or fifteen are children still; some are grown up, with the +tastes, feelings, and attraction of maturity. Those who have developed +fastest are often, for that very reason, kept backward in school +learning. Often they are nervously the least stable. Now that large +schools for girls on the model of our public schools are become the +fashion, such precociously developed and nervously unstable girls are +apt to find themselves in the very uncongenial society of little girls +of twelve or thirteen. The elder girls commonly hold aloof, while +mistresses are apt to view this precocious development with +disapproval, and to attempt to retard what cannot be retarded by +insisting that the young woman has remained a child. I remember being +called in consultation by a surgeon who had been asked to operate for +appendicitis upon a girl of fourteen. I found a tall, well-grown girl, +with an appearance and manner that made her look four years older. I +could find no signs of appendicitis, but I learned from her that she +had been for three months at a large girls' school, and that in a few +days' time her second term was due to begin. As we became friends, she +agreed that her appendicitis and her resolve not +<span class="pagenum">Page 189<a name="Page_189" id="Page_189"></a></span> +to return to school, +where she was unhappy, were but different ways of saying the same +thing. She was an only child who had travelled a great deal with her +parents, had found her interests in their pursuits, and had grown +backward in school work. The little girls with whom she was expected +to associate seemed to her mere children. The elder girls did not want +her friendship, and snubbed her. I prescribed a change to a small +boarding-school with only a few girls, where age differences would not +matter so much, and where she could make friends with girls older than +herself, though not more mature.</p> + +<p>Into their school life we need not follow the children. Happily the +time is past when schoolmasters and schoolmistresses were incapable of +understanding their charges, and confounded nervous exhaustion with +stupidity or timidity with incapacity.</p> + +<p>And so we come back to the point from which we started:</p> + +<p>The nervous infant, restless, wriggling, and constantly crying! The +nervous child, unstable, suggestible, passionate, and full of nameless +fears! The nervous schoolboy or schoolgirl prone to self-analysis, +subject-conscious, and easily exhausted! And how many and how various +are the manifestations of this temperament! Refusal of food, refusal +of sleep, negativism, irritability, and violent fits of temper, +vomiting, diarrhœa, morbid flushing and blushing, habit spasms, +phobias—all controlled not by reproof or by +<span class="pagenum">Page 190<a name="Page_190" id="Page_190"></a></span> +medicine, but by good management and a clear understanding of their nature.</p> + +<p>The hygiene of the child's mind is as important as the hygiene of his +body, and both are studies proper for the doctor. Neuropathy and an +unsound, nervous organisation are often enough legacies from the +nervous disorders of childhood.</p> +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 191<a name="Page_191" id="Page_191"></a></span></p> +<h3>INDEX</h3> +<p> </p> + +<p>Abdomen, prominent, <a href="#Page_151">151</a><br /> +<br /> +Abdominal symptoms of neurosis, <a href="#Page_153">153</a><br /> +<br /> +Accent, local, facility with which acquired, <a href="#Page_17">17</a><br /> +<br /> +Acetone, in breath and urine during cyclic vomiting, <a href="#Page_86">86</a><br /> +<br /> +Acidosis, accompanying cyclic vomiting, <a href="#Page_85">85</a><br /> +<br /> +Action, imitativeness of, <a href="#Page_19">19</a><br /> +<span class="in1">liberty of, in early childhood, <a href="#Page_22">22</a></span><br /> +<br /> +Activities in the nursery, <a href="#Page_98">98</a><br /> +<span class="in1">not to be restrained, <a href="#Page_23">23</a>, <a href="#Page_24">24</a>, +<a href="#Page_98">98</a></span><br /> +<span class="in1">without intervention of grown-up people, <a href="#Page_99">99</a></span><br /> +<span class="in1">wonderful nature of, <a href="#Page_24">24</a></span><br /> +<br /> +Adenoid vegetations, night-terrors aggravated by, <a href="#Page_136">136</a><br /> +<span class="in1">removal of, in treatment of enuresis, <a href="#Page_93">93</a></span><br /> +<br /> +Adolescence, and education on sexual matters, <a href="#Page_169">169</a>, <a href="#Page_175">175</a><br /> +<br /> +Adults, child in relation to the society of, <a href="#Page_36">36</a>, <a href="#Page_38">38</a><br /> +<br /> +Æsthetic sense, in early childhood, <a href="#Page_48">48</a><br /> +<br /> +Affection, in the child, <a href="#Page_48">48</a><br /> +<br /> +Air hunger, in cyclic vomiting, <a href="#Page_86">86</a><br /> +<br /> +Air swallowing, habitual action of, <a href="#Page_79">79</a><br /> +<br /> +Albuminuria, associated with faulty posture, <a href="#Page_152">152</a><br /> +<span class="in1">cause of, in neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Allimentary disturbances, symptom of, <a href="#Page_157">157</a><br /> +<br /> +Alkali, in treatment of cyclic vomiting, <a href="#Page_87">87</a><br /> +<br /> +Anæmia, of neuropaths, <a href="#Page_152">152</a><br /> +<br /> +Anorexia nervosa, <a href="#Page_50">50</a><br /> +<span class="in1">A case illustrating, <a href="#Page_50">50</a></span><br /> +<br /> +Apnœa, fatal cases of, <a href="#Page_83">83</a><br /> +<span class="in1">following burst of crying, <a href="#Page_82">82</a></span><br /> +<span class="in1">twitching of facial muscles in, <a href="#Page_83">83</a></span><br /> +<br /> +Appetite, emotional states affecting, <a href="#Page_52">52</a><br /> +<span class="in1">loss of, <a href="#Page_51">51</a></span><br /> +<span class="in2">case illustrating, <a href="#Page_51">51</a></span><br /> +<span class="in2">causes and characteristics, <a href="#Page_56">56</a>, <a href="#Page_62">62</a></span><br /> +<span class="in2">treatment, <a href="#Page_62">62</a></span><br /> +<span class="in1">means of stimulating, <a href="#Page_53">53</a></span><br /> +<span class="in1">nature of the sensation of, <a href="#Page_52">52</a></span><br /> +<br /> +Apprehension, causes of, <a href="#Page_28">28</a><br /> +<span class="in1">growth of neuroses in atmosphere of, <a href="#Page_75">75</a></span><br /> +<br /> +Artificial feeding, <a href="#Page_109">109</a>, <a href="#Page_113">113</a><br /> +<br /> +Aspirin, <a href="#Page_71">71</a><br /> +<br /> +Asthma, treatment of, <a href="#Page_166">166</a><br /> +<br /> +Attention, child's love of attracting, <a href="#Page_32">32</a>, <a href="#Page_35">35</a>, <a href="#Page_59">59</a><br /> +<span class="in1">examples of, <a href="#Page_33">33</a>, <a href="#Page_39">39</a></span><br /> +<br /> +Authority, delight in defying, <a href="#Page_43">43</a>-46<br /> +<span class="in1">over-exercise of, by parents, results of, <a href="#Page_42">42</a>, +<a href="#Page_43">43</a>, <a href="#Page_45">45</a></span><br /> + <br /></p> + +<p>Babies. <i>See</i> Newborn Baby<br /> +<br /> +Backward development, <a href="#Page_56">56</a>, <a href="#Page_146">146</a><br /> +<span class="in1">signs of, <a href="#Page_56">56</a></span><br /> +<br /> +"Bad form," <a href="#Page_183">183</a><br /> +<br /> +Bad habits, <a href="#Page_77">77</a>-80<br /> +<br /> +Bath, baby's first experience of, <a href="#Page_105">105</a>, <a href="#Page_106">106</a><br /> +<br /> +Bed, dislike of, <a href="#Page_28">28</a><br /> +<span class="in1">how overcome, <a href="#Page_28">28</a>, <a href="#Page_29">29</a></span><br /> +<span class="in1">efforts to resist preparation for, <a href="#Page_64">64</a>, +<a href="#Page_65">65</a>, <a href="#Page_66">66</a></span><br /> +<br /> +Bedroom, airing and temperature of, <a href="#Page_69">69</a><br /> +<br /> +Bedtime, <a href="#Page_64">64</a>, <a href="#Page_66">66</a><br /> +<span class="in1">management at, <a href="#Page_65">65</a>, <a href="#Page_66">66</a></span><br /> +<br /> +Bed wetting. <i>See</i> Enuresis<br /> + +<span class="pagenum">Page 192<a name="Page_192" id="Page_192"></a></span> + +<br /> +Behaviour. <i>See</i> Conduct<br /> +<br /> +Bladder, hydrostatic distension of, for enuresis, <a href="#Page_92">92</a>, <a href="#Page_93">93</a><br /> +<br /> +Boarding-schools, object of, <a href="#Page_183">183</a><br /> +<br /> +Bodily ailments, and instability of nervous control, connection<br /> +<span class="in1">between, <a href="#Page_120">120</a></span><br /> +<span class="in1"><i>See also</i> Disorders</span><br /> +<br /> +Body,<br /> +<span class="in1">and mind, development of, <a href="#Page_120">120</a>, <a href="#Page_121">121</a></span><br /> +<span class="in1">development of, <a href="#Page_146">146</a></span><br /> +<span class="in2">environment influencing, <a href="#Page_5">5</a></span><br /> +<span class="in1">effect of mind on, <a href="#Page_51">51</a></span><br /> +<span class="in1">gradual alterations in the shape of, <a href="#Page_146">146</a></span><br /> +<span class="in1">infantile characteristics in later childhood, <a href="#Page_145">145</a>, +<a href="#Page_146">146</a></span><br /> +<br /> +Bone, and muscle, changes in, in infantile children, <a href="#Page_148">148</a><br /> +<br /> +Books,<br /> +<span class="in1">child's attitude towards, <a href="#Page_99">99</a></span><br /> +<span class="in1">educative value of, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<span class="in1">kinds most suitable, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<br /> +Brachial nerve, pressure causing tetany, <a href="#Page_81">81</a><br /> +<br /> +Breast-feeding,<br /> +<span class="in1">best time for, <a href="#Page_109">109</a></span><br /> +<span class="in1">causes of failure in, <a href="#Page_108">108</a></span><br /> +<span class="in1">observations on, <a href="#Page_106">106</a></span><br /> +<span class="in1"><i>See also</i> Lactation</span><br /> +<br /> +Breath-holding, <a href="#Page_81">81</a>, <a href="#Page_82">82</a><br /> +<span class="in1">action during, <a href="#Page_84">84</a></span><br /> +<span class="in1">fatal cases of, <a href="#Page_83">83</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_82">82</a></span><br /> +<br /> +Bromides, administration of, <a href="#Page_71">71</a><br /> +<span class="in1">to newborn baby, <a href="#Page_110">110</a>, <a href="#Page_111">111</a></span><br /> + <br /></p> + +<p>Cajoling, futility of, <a href="#Page_26">26</a><br /> +<br /> +Calcium bromide, in treatment of spasms, <a href="#Page_84">84</a><br /> +<br /> +Calcium metabolism, disturbance of, <a href="#Page_82">82</a><br /> +<br /> +Care, ill effects of excess of, <a href="#Page_163">163</a><br /> +<br /> +Carpo-pedal spasm, <a href="#Page_81">81</a><br /> +<br /> +Catarrhal infections, <a href="#Page_155">155</a><br /> +<span class="in1">connection of rheumatism with, <a href="#Page_155">155</a></span><br /> +<br /> +Cerebral anæmia, <a href="#Page_140">140</a><br /> +<br /> +Cerebral circulation, stagnation of, <a href="#Page_140">140</a><br /> +<br /> +Cerebral exhaustion. <i>See</i> Mental Exhaustion<br /> +<br /> +Cerebral functions,<br /> +<span class="in1">rapid growth of, <a href="#Page_5">5</a></span><br /> +<span class="in1">unstable in the child, <a href="#Page_6">6</a></span><br /> +<span class="in1"><i>See also</i> Mental</span><br /> +<br /> +Character,<br /> +<span class="in1">formation of, <a href="#Page_126">126</a></span><br /> +<span class="in1">during school life, <a href="#Page_184">184</a>, <a href="#Page_186">186</a></span><br /> +<span class="in1">home influence in the development of, <a href="#Page_182">182</a>, +<a href="#Page_185">185</a>, <a href="#Page_186">186</a></span><br /> +<span class="in1">ideals of, how inculcated, <a href="#Page_125">125</a></span><br /> +<br /> +Children's parties, disadvantages of, <a href="#Page_102">102</a><br /> +<br /> +Chloral, administration of, <a href="#Page_71">71</a><br /> +<span class="in2">to newborn baby, <a href="#Page_110">110</a>, <a href="#Page_111">111</a></span><br /> +<span class="in1">in treatment of spasms, <a href="#Page_84">84</a></span><br /> +<br /> +Chorea, <a href="#Page_155">155</a><br /> +<span class="in1">and rheumatism, association between, <a href="#Page_155">155</a></span><br /> +<span class="in1">symptom of cerebral irritability, <a href="#Page_156">156</a></span><br /> +<span class="in1">treatment of, <a href="#Page_156">156</a></span><br /> +<br /> +Chvostek's sign, characteristics and nature of, <a href="#Page_81">81</a><br /> +<br /> +Circulation, cerebral,<br /> +<span class="in1">stagnation of, <a href="#Page_140">140</a></span><br /> +<span class="in1">nervous control of, <a href="#Page_140">140</a></span><br /> +<br /> +Claustrophobia, <a href="#Page_180">180</a><br /> +<br /> +Clothing,<br /> +<span class="in1">kind suitable, <a href="#Page_69">69</a></span><br /> +<span class="in1">new, child's delight in, <a href="#Page_48">48</a></span><br /> +<br /> +Coaxing, <a href="#Page_67">67</a><br /> +<span class="in1">futility of, 26</span><br /> +<br /> +Cold douches, improving vasomotor tone, <a href="#Page_154">154</a><br /> +<br /> +Coldness of extremities, <a href="#Page_141">141</a><br /> +<br /> +Conduct,<br /> +<span class="in1">control of, factors in, <a href="#Page_33">33</a>, <a href="#Page_129">129</a></span><br /> +<span class="in1">errors of, and sexual instincts, <a href="#Page_176">176</a></span><br /> +<span class="in2">control of, <a href="#Page_39">39</a></span><br /> +<span class="in2">correction of, <a href="#Page_127">127</a></span><br /> +<span class="in2">due to faults of management, <a href="#Page_127">127</a></span><br /> +<span class="in2">in neuropathic children, <a href="#Page_126">126</a></span><br /> +<span class="in1">excessive introspection influencing, <a href="#Page_139">139</a></span><br /> +<span class="in1">ideals of, how inculcated, <a href="#Page_125">125</a></span><br /> +<span class="in1">influence of environment on, <a href="#Page_131">131</a></span><br /> +<span class="in1">influenced by suggestion, <a href="#Page_13">13</a></span><br /> +<span class="in1">mother's influence on, <a href="#Page_11">11</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">perverse, <a href="#Page_45">45</a></span><br /> +<span class="in1">suggestion in the control of, <a href="#Page_130">130</a></span><br /> + +<span class="pagenum">Page 193<a name="Page_193" id="Page_193"></a></span> + +<br /> +Constipation, <a href="#Page_12">12</a><br /> +<span class="in1">mental causes of, <a href="#Page_30">30</a>, <a href="#Page_80">80</a></span><br /> +<span class="in1">negativism in, <a href="#Page_80">80</a></span><br /> +<span class="in1">perversion of suggestion a common cause of, <a href="#Page_30">30</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_80">80</a></span><br /> +<br /> +Constitution, delicacy of, <a href="#Page_161">161</a><br /> +<br /> +Convulsions, fatal cases of, <a href="#Page_83">83</a><br /> +<span class="in1">generalised, <a href="#Page_81">81</a></span><br /> +<br /> +Convulsive disorders, <a href="#Page_149">149</a>, <a href="#Page_150">150</a><br /> +<br /> +Cough, nervous, <a href="#Page_73">73</a><br /> +<br /> +Counter-opposition, child's opposition growing with, <a href="#Page_60">60</a>, <a href="#Page_67">67</a>, +<a href="#Page_179">179</a><br /> +<br /> +Crying, constant, <a href="#Page_54">54</a>, <a href="#Page_67">67</a><br /> +<span class="in1">formation of habit of, <a href="#Page_115">115</a></span><br /> +<span class="in1">in emotional and excitable children, <a href="#Page_82">82</a></span><br /> +<span class="in1">management of, <a href="#Page_68">68</a></span><br /> +<span class="in1">mechanism of, <a href="#Page_149">149</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_67">67</a></span><br /> +<span class="in1">purposeful, <a href="#Page_68">68</a></span><br /> +<br /> +Cyclic or periodic vomiting. <i>See</i> Vomiting<br /> + <br /></p> + +<p>Day-dreams, indicating nervous temperament, <a href="#Page_137">137</a><br /> +<br /> +Deceit, <a href="#Page_123">123</a>, <a href="#Page_124">124</a><br /> +<br /> +Defæcation, inhibition of, <a href="#Page_11">11</a>, <a href="#Page_12">12</a>, <a href="#Page_13">13</a><br /> +<span class="in1">painful, <a href="#Page_2">2</a></span><br /> +<br /> +Delicacy of constitution, <a href="#Page_161">161</a><br /> +<br /> +Delirium, tendency to, <a href="#Page_161">161</a>, <a href="#Page_162">162</a><br /> +<br /> +Depolarisation of ideas, <a href="#Page_172">172</a><br /> +<br /> +Depression, recurrence of periods of, <a href="#Page_61">61</a><br /> +<br /> +Dexterity, lack of, <a href="#Page_56">56</a><br /> +<span class="in1">manual, advantages of, <a href="#Page_122">122</a></span><br /> +<span class="in1">toys developing, <a href="#Page_96">96</a></span><br /> +<br /> +Diaphragm, spasm of, <a href="#Page_82">82</a><br /> +<br /> +Diarrhoea, mucous, <a href="#Page_142">142</a><br /> +<br /> +Diet, likes and dislikes for articles of, <a href="#Page_25">25</a><br /> +<span class="in1">opposition to, <a href="#Page_25">25</a></span><br /> +<span class="in1">of newborn child, changes in, <a href="#Page_113">113</a></span><br /> +<span class="in1"><i>See also</i> Food</span><br /> +<br /> +Digestion, emotional states affecting, <a href="#Page_52">52</a>, <a href="#Page_53">53</a><br /> +<br /> +Digestive disorders, mental causes of, <a href="#Page_51">51</a>, <a href="#Page_52">52</a>, <a href="#Page_62">62</a><br /> +<br /> +Digestive neuroses, <a href="#Page_50">50</a><br /> +<br /> +Digestive system, symptoms of extreme sensibility of, <a href="#Page_141">141</a><br /> +<br /> +Dirt eating, <a href="#Page_80">80</a><br /> +<br /> +Discipline, <a href="#Page_43">43</a><br /> +<span class="in1">in later childhood, <a href="#Page_118">118</a></span><br /> +<span class="in1">in the school, <a href="#Page_183">183</a></span><br /> +<span class="in1">misdirected efforts at enforcing, <a href="#Page_44">44</a></span><br /> +<span class="in1">severe, effects of, <a href="#Page_119">119</a></span><br /> +<br /> +Dishonesty, <a href="#Page_127">127</a><br /> +<br /> +Disobedience, <a href="#Page_43">43</a>, <a href="#Page_45">45</a><br /> +<span class="in1">growth of, <a href="#Page_42">42</a></span><br /> +<span class="in1">habit of, <a href="#Page_59">59</a></span><br /> +<span class="in1">personality and, <a href="#Page_58">58</a></span><br /> +<span class="in1">perverse attitude of, <a href="#Page_34">34</a></span><br /> +<span class="in1">reproof and coaxing causing, <a href="#Page_61">61</a></span><br /> +<br /> +Disorders, ætiology of, <a href="#Page_14">14</a><br /> +<span class="in1">associated with neurosis, <a href="#Page_145">145</a></span><br /> +<span class="in1">common, <a href="#Page_140">140</a>-141</span><br /> +<span class="in1">environment as cause and cure of, <a href="#Page_142">142</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_145">145</a>-159</span><br /> +<span class="in1">treatment of, <a href="#Page_142">142</a></span><br /> +<span class="in1">trifling, <a href="#Page_162">162</a></span><br /> +<br /> +Diuresis, excessive, <a href="#Page_141">141</a><br /> +<br /> +Doll, child's care of, an example of imitativeness, <a href="#Page_23">23</a><br /> +<span class="in1">educative value of, <a href="#Page_98">98</a></span><br /> +<br /> +Douches, cold, improving vasomotor tone, <a href="#Page_154">154</a><br /> +<br /> +Dover's powder, <a href="#Page_72">72</a><br /> +<br /> +Dreams, <a href="#Page_70">70</a><br /> +<span class="in1">nature of, indicating nature of mental unrest, <a href="#Page_137">137</a></span><br /> +<br /> +Drugs, in sleeplessness, <a href="#Page_70">70</a>, <a href="#Page_71">71</a><br /> +<br /> +Ductless glands, in relation to infantile characteristics, <a href="#Page_147">147</a><br /> +<br /> +Dullards, <a href="#Page_149">149</a><br /> +<br /> +Dyspepsia, complications of, <a href="#Page_54">54</a><br /> +<span class="in1">course and effects of, <a href="#Page_54">54</a></span><br /> +<span class="in1">mental aspects of, <a href="#Page_53">53</a></span><br /> +<span class="in1">nervous symptoms of, <a href="#Page_53">53</a>, <a href="#Page_54">54</a></span><br /> +<span class="in1">symptoms in newborn infant, <a href="#Page_116">116</a></span><br /> +<span class="in1">treatment, <a href="#Page_63">63</a></span><br /> + <br /></p> + + +<p>Early childhood, care during, <a href="#Page_105">105</a><br /> +<span class="in1">impulse of opposition in, <a href="#Page_35">35</a></span><br /> +<span class="in1">love of power in, <a href="#Page_32">32</a>, <a href="#Page_36">36</a></span><br /> + +<span class="pagenum">Page 194<a name="Page_194" id="Page_194"></a></span> + +<br /> +Early childhood, nervousness in, <a href="#Page_104">104</a><br /> +<span class="in1">reasoning power in, <a href="#Page_40">40</a></span><br /> +<span class="in1">three common neuroses of, <a href="#Page_74">74</a></span><br /> +<span class="in1">toys, books, and amusements in, <a href="#Page_96">96</a></span><br /> +<span class="in1"><i>See also</i> Newborn Baby</span><br /> +<br /> +Education, aim of, <a href="#Page_118">118</a>-120<br /> +<span class="in1">by games and toys, <a href="#Page_96">96</a></span><br /> +<span class="in1">on sexual matters, <a href="#Page_169">169</a></span><br /> +<br /> +Educative value, of books, games, and toys, <a href="#Page_98">98</a>-100<br /> +<br /> +Emotional states, appetite affected by, <a href="#Page_52">52</a><br /> +<span class="in1">causing spasm, <a href="#Page_83">83</a></span><br /> +<span class="in1">management of, <a href="#Page_82">82</a></span><br /> +<span class="in1">of neurotics, exaggeration of, <a href="#Page_131">131</a></span><br /> +<span class="in1">physical disturbances due to, <a href="#Page_53">53</a>, <a href="#Page_54">54</a></span><br /> +<span class="in1">producing laryngismus stridulus, <a href="#Page_82">82</a></span><br /> +<br /> +Emotional storms, <a href="#Page_68">68</a><br /> +<br /> +Endocrine glands, <a href="#Page_147">147</a><br /> +<br /> +Enuresis, <a href="#Page_81">81</a>, <a href="#Page_89">89</a><br /> +<span class="in1">causal factors in, <a href="#Page_89">89</a>, <a href="#Page_90">90</a></span><br /> +<span class="in1">characteristics and peculiarities of, <a href="#Page_90">90</a>-92</span><br /> +<span class="in1">condition of urine during, <a href="#Page_93">93</a></span><br /> +<span class="in1">mental aspects of, <a href="#Page_95">95</a></span><br /> +<span class="in1">mistakes in treatment of, <a href="#Page_94">94</a></span><br /> +<span class="in1">perversion of suggestion as cause of, <a href="#Page_89">89</a></span><br /> +<span class="in1">removal of tonsils in, <a href="#Page_92">92</a>, <a href="#Page_93">93</a></span><br /> +<span class="in1">treatment, essentials in, <a href="#Page_94">94</a></span><br /> +<span class="in2">hypnotic suggestion in, <a href="#Page_95">95</a></span><br /> +<span class="in2">methods of, <a href="#Page_92">92</a>-93</span><br /> +<br /> +Environment, body moulded and shaped by, <a href="#Page_5">5</a><br /> +<span class="in1">change of, beneficial effects of, <a href="#Page_13">13</a></span><br /> +<span class="in1">effect in developing child's powers, <a href="#Page_22">22</a></span><br /> +<span class="in1">effect on common disorders, <a href="#Page_142">142</a></span><br /> +<span class="in1">errors of, and neuropathic children, <a href="#Page_126">126</a></span><br /> +<span class="in1">essentials of, <a href="#Page_39">39</a></span><br /> +<span class="in1">faulty contact with, in neuropathic children, <a href="#Page_138">138</a></span><br /> +<span class="in1">for neuropaths, <a href="#Page_132">132</a></span><br /> +<span class="in1">influence on conduct in later childhood, <a href="#Page_131">131</a></span><br /> +<span class="in1">influence on mental processes, <a href="#Page_10">10</a></span><br /> +<span class="in1">influence on personality, <a href="#Page_24">24</a>, <a href="#Page_25">25</a></span><br /> +<span class="in1">irritating nature of the adult mind in, <a href="#Page_36">36</a>, <a href="#Page_38">38</a></span><br /> +<span class="in1">of the home, reflected in the child, <a href="#Page_182">182</a></span><br /> +<span class="in1">of school life, <a href="#Page_183">183</a>-186</span><br /> +<span class="in1">stimulus of, <a href="#Page_22">22</a></span><br /> +<span class="in1">susceptibility to influences of, <a href="#Page_25">25</a>, <a href="#Page_31">31</a></span><br /> +<br /> +Epilepsy, cyclical character of, <a href="#Page_61">61</a><br /> +<br /> +Evil, inborn disposition to, <a href="#Page_130">130</a><br /> +<br /> +Excitable children, management of, <a href="#Page_82">82</a><br /> +<br /> +Exercise, sleep in relation to, <a href="#Page_69">69</a><br /> +<br /> +Exhaustion. <i>See</i> Mental Exhaustion<br /> +<br /> +Expostulation, frequent, bad effects of, <a href="#Page_124">124</a>, <a href="#Page_125">125</a><br /> +<span class="in1"><i>See also</i> Reproof</span><br /> +<br /> +Expressions, to attract attention, <a href="#Page_39">39</a><br /> + <br /> +</p> + + +<p>Facial muscles, twitching of, <a href="#Page_81">81</a><br /> +<span class="in1">associated with apnœa, <a href="#Page_83">83</a></span><br /> +<br /> +Fæces, incontinence of, <a href="#Page_92">92</a><br /> +<br /> +Fainting fits, <a href="#Page_140">140</a><br /> +<span class="in1">cause and characteristics, <a href="#Page_140">140</a></span><br /> +<span class="in1">control of, <a href="#Page_141">141</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Fatigue, mental, physical, and visceral, <a href="#Page_143">143</a><br /> +<br /> +Fats, lowered tolerance to, <a href="#Page_87">87</a><br /> +<br /> +Faults, correction of, <a href="#Page_127">127</a><br /> +<span class="in1">not corrected by too frequent reproof, <a href="#Page_124">124</a>, <a href="#Page_125">125</a></span><br /> +<br /> +Fear, <a href="#Page_39">39</a><br /> +<span class="in1">causes of, <a href="#Page_28">28</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_134">134</a>, <a href="#Page_135">135</a></span><br /> +<span class="in1">prominent psychical symptom of neuropathic children, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">treatment of, <a href="#Page_135">135</a></span><br /> +<br /> +Feeding, <a href="#Page_55">55</a><br /> +<span class="in1">artificial, <a href="#Page_109">109</a>, <a href="#Page_113">113</a></span><br /> +<span class="in1">factors in, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in1">of newborn infant, regularity in, <a href="#Page_116">116</a></span><br /> +<br /> +Fertilisation, method of imparting knowledge of, <a href="#Page_174">174</a><br /> + +<span class="pagenum">Page 195<a name="Page_195" id="Page_195"></a></span> + +<br /> +Food, force of suggestion in relation to, <a href="#Page_25">25</a>-27<br /> +<span class="in1">healthy desire for, <a href="#Page_62">62</a></span><br /> +<span class="in1">likes and dislikes for, <a href="#Page_25">25</a></span><br /> +<span class="in2">how overcome, <a href="#Page_26">26</a></span><br /> +<span class="in1">phenomena of the desire of, <a href="#Page_52">52</a></span><br /> +<span class="in1">refusal of, <a href="#Page_35">35</a>, <a href="#Page_50">50</a></span><br /> +<span class="in2">nervous causes of, <a href="#Page_52">52</a></span><br /> +<span class="in2">persistent, factors encouraging, <a href="#Page_57">57</a></span><br /> +<span class="in2">suggestion in relation to, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in2">treatment of, <a href="#Page_26">26</a>, <a href="#Page_55">55</a>, <a href="#Page_62">62</a></span><br /> +<br /> +Force and cajoling, futility of, <a href="#Page_26">26</a><br /> +<br /> +Freud, teaching of, <a href="#Page_176">176</a><br /> +<br /> +Functional disturbances, in combination with organic disease, <a href="#Page_4">4</a><br /> + <br /> +</p> + +<p>Gait, peculiarity of, <a href="#Page_74">74</a><br /> +<br /> +Games, educative value of, <a href="#Page_96">96</a>, <a href="#Page_98">98</a><br /> +<br /> +Gastric disturbances, <a href="#Page_54">54</a><br /> +<br /> +Gastric juice, psychic secretion of, <a href="#Page_52">52</a><br /> +<br /> +Gastric symptoms, of neurosis, <a href="#Page_153">153</a><br /> +<br /> +Gastro-intestinal derangement, causes of, <a href="#Page_141">141</a><br /> +<span class="in1">environment as cause and cure of, <a href="#Page_142">142</a></span><br /> +<br /> +Gentleness, <a href="#Page_119">119</a><br /> +<span class="in1">inculcation of, <a href="#Page_129">129</a></span><br /> +<br /> +Girls' schools, <a href="#Page_188">188</a><br /> +<br /> +Glottis, spasm of, strong emotion causing, <a href="#Page_82">82</a><br /> +<br /> +"Good form," <a href="#Page_183">183</a>, <a href="#Page_184">184</a><br /> +<br /> +Grasping habit, reproof in relation to, <a href="#Page_21">21</a><br /> +<br /> +Growing pains, <a href="#Page_167">167</a><br /> + <br /> +</p> + +<p>Habit spasms, age of appearance of, <a href="#Page_74">74</a><br /> +<span class="in1">cause of, <a href="#Page_74">74</a></span><br /> +<span class="in1">definition of, <a href="#Page_73">73</a></span><br /> +<span class="in1">examples of, <a href="#Page_73">73</a></span><br /> +<span class="in1">spread of, <a href="#Page_75">75</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_74">74</a></span><br /> +<span class="in1">treatment of, <a href="#Page_76">76</a></span><br /> +<br /> +Habits, regulation of, <a href="#Page_30">30</a><br /> +<span class="in1">suggestion in relation to, <a href="#Page_30">30</a></span><br /> +<br /> +Habitual actions, infant's pleasure in, <a href="#Page_77">77</a><br /> +<span class="in1">mental unrest in relation to, <a href="#Page_77">77</a></span><br /> +<span class="in1">of the parent, reproduction in the child, <a href="#Page_75">75</a></span><br /> +<span class="in1">varieties and characteristics, <a href="#Page_77">77</a></span><br /> +<br /> +Habitual wakefulness, <a href="#Page_70">70</a><br /> +<br /> +Hands, control of movement of, <a href="#Page_19">19</a>, <a href="#Page_22">22</a><br /> +<span class="in1">expressionless, <a href="#Page_56">56</a></span><br /> +<br /> +Happiness and contentment, of child when playing alone, <a href="#Page_96">96</a><br /> +<br /> +Headache, periodic. <i>See</i> Migraine<br /> +<br /> +Heat and cold, newborn baby in relation to, <a href="#Page_106">106</a><br /> +<br /> +Heat and flushing, sudden sensations of, <a href="#Page_141">141</a><br /> +<br /> +Heredity, and temperament, <a href="#Page_10">10</a><br /> +<span class="in1">and type of child, <a href="#Page_31">31</a></span><br /> +<span class="in1">nervous disorders in relation to, <a href="#Page_5">5</a></span><br /> +<br /> +Home influence, in development of character, <a href="#Page_182">182</a>, <a href="#Page_185">185</a>, <a href="#Page_186">186</a><br /> +<span class="in1">reflected in the child, <a href="#Page_182">182</a></span><br /> +<br /> +Hunger, of the newborn baby, <a href="#Page_105">105</a>, <a href="#Page_109">109</a><br /> +<br /> +Hypnotic suggestion, in treatment of enuresis, <a href="#Page_95">95</a><br /> +<br /> +Hypnotics, <a href="#Page_70">70</a>, <a href="#Page_71">71</a><br /> +<br /> +Hysteria, <a href="#Page_158">158</a><br /> +<span class="in1">age of appearance of, <a href="#Page_158">158</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_32">32</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_158">158</a></span><br /> +<br /> +Hysterical girls, characteristics of, <a href="#Page_32">32</a><br /> + <br /></p> + + +<p>Ideals, inculcation of, <a href="#Page_118">118</a>-119<br /> +<br /> +Ideas, polarisation and depolarisation of, <a href="#Page_172">172</a><br /> +<br /> +Illness. <i>See</i> Sickness<br /> +<br /> +Imagination, abnormal, correction of, <a href="#Page_138">138</a><br /> +<span class="in1">child's stories and tales in relation to, 137, 138</span><br /> +<span class="in1">developed by toys, <a href="#Page_98">98</a></span><br /> +<br /> +Imitativeness, age at which apparent, <a href="#Page_16">16</a><br /> +<span class="in1">extent of, <a href="#Page_23">23</a></span><br /> +<span class="in1">illustration of, <a href="#Page_17">17</a>, <a href="#Page_23">23</a></span><br /> +<span class="in1">lack of, <a href="#Page_56">56</a></span><br /> +<span class="in1">of action, <a href="#Page_19">19</a></span><br /> +<span class="in1">of speech, <a href="#Page_17">17</a>, <a href="#Page_18">18</a></span><br /> +<span class="in1">tell-tale child an illustration of, <a href="#Page_18">18</a></span><br /> + +<span class="pagenum">Page 196<a name="Page_196" id="Page_196"></a></span> + +<br /> +Incontinence of urine, <a href="#Page_89">89</a>-<a href="#Page_95">95</a><br /> +<br /> +Incorrigible children, <a href="#Page_129">129</a><br /> +<br /> +Infantile characteristics, <a href="#Page_146">146</a><br /> +<span class="in1">ductless glands in relation to, <a href="#Page_147">147</a></span><br /> +<span class="in1">nervous system in relation to, <a href="#Page_149">149</a>, <a href="#Page_150">150</a></span><br /> +<br /> +Infective disorders,<br /> +<span class="in1">convalescence from, <a href="#Page_157">157</a></span><br /> +<span class="in1">producing nervous symptoms, <a href="#Page_167">167</a></span><br /> +<span class="in1">relation of neurosis to, <a href="#Page_167">167</a></span><br /> +<br /> +Inflammatory reactions, <a href="#Page_147">147</a><br /> +<br /> +Insomnia. <i>See</i> Sleeplessness<br /> +<br /> +Intellect, compared with physique, <a href="#Page_120">120</a><br /> +<br /> +Intelligence, in early childhood, <a href="#Page_40">40</a>, <a href="#Page_41">41</a>, <a href="#Page_42">42</a><br /> +<br /> +Intestinal disturbance, <a href="#Page_54">54</a><br /> +<span class="in1">of neurosis, <a href="#Page_153">153</a></span><br /> +<span class="in1">symptom of, <a href="#Page_157">157</a></span><br /> +<br /> +Intoxications, violent reaction to, <a href="#Page_142">142</a><br /> +<br /> +Introspection, and neuropathic children, <a href="#Page_138">138</a><br /> +<span class="in1">excessive, evidences of, <a href="#Page_139">139</a></span><br /> +<span class="in2">influencing conduct, <a href="#Page_139">139</a></span><br /> +<br /> +Irritation, child to be free from, <a href="#Page_40">40</a><br /> + <br /></p> + +<p>Joint pains, <a href="#Page_167">167</a><br /> +<br /> +<br /> +Kindergarten school, artificial symbolism of, <a href="#Page_24">24</a><br /> +<br /> +Kindness, inculcation of, <a href="#Page_129">129</a><br /> + <br /> +</p> + +<p> +Lactation,<br /> +<span class="in1">care of child during, <a href="#Page_106">106</a>, <a href="#Page_109">109</a></span><br /> +<span class="in1">care of mother during, <a href="#Page_110">110</a></span><br /> +<span class="in1">causes of failure in, <a href="#Page_108">108</a></span><br /> +<span class="in1">establishment of, <a href="#Page_106">106</a>, <a href="#Page_107">107</a></span><br /> +<span class="in1">tongue-tie in relation to, <a href="#Page_12">12</a></span><br /> +<br /> +Laryngismus stridulus. <i>See</i> Breath-holding<br /> +<br /> +Later childhood,<br /> +<span class="in1">infantile characteristics in, <a href="#Page_146">146</a></span><br /> +<span class="in1">management in, <a href="#Page_117">117</a>-130</span><br /> +<span class="in1">mental backwardness in, <a href="#Page_146">146</a></span><br /> +<br /> +Likes and dislikes, <a href="#Page_25">25</a><br /> +<br /> +Lordosis, <a href="#Page_151">151</a><br /> +<span class="in1">and neurosis, <a href="#Page_151">151</a></span><br /> +<span class="in1">producing albuminuria, <a href="#Page_152">152</a></span><br /> + <br /></p> + +<p>Manual dexterity, advantages of, <a href="#Page_122">122</a><br /> +<br /> +Massage, improving tone of muscles, <a href="#Page_154">154</a><br /> +<br /> +Medicines, sensitiveness to, <a href="#Page_26">26</a><br /> +<br /> +Melancholy children, <a href="#Page_157">157</a><br /> +<br /> +Mental aspects, of digestive disorders, <a href="#Page_51">51</a>-54<br /> +<span class="in1">of enuresis, <a href="#Page_95">95</a></span><br /> +<span class="in1">of management in early childhood, <a href="#Page_31">31</a></span><br /> +<br /> +Mental backwardness,<br /> +<span class="in1">and infantile characteristics, <a href="#Page_146">146</a></span><br /> +<span class="in1">in later childhood, <a href="#Page_146">146</a></span><br /> +<br /> +Mental disturbances,<br /> +<span class="in1">cyclical character of, <a href="#Page_61">61</a></span><br /> +<span class="in1">indicating neuropathic tendencies, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">irregularities of sleep due to, <a href="#Page_68">68</a></span><br /> +<span class="in1">psycho-analysis of, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<br /> +Mental exhaustion,<br /> +<span class="in1">during convalescence from infective disorders, <a href="#Page_157">157</a></span><br /> +<span class="in1">easily produced in nervous children, <a href="#Page_143">143</a></span><br /> +<br /> +Mental irritability, chorea a symptom of, <a href="#Page_156">156</a><br /> +<br /> +Mental life of the child, <a href="#Page_101">101</a><br /> +<br /> +Mental power,<br /> +<span class="in1">active before beginning of speech, <a href="#Page_40">40</a></span><br /> +<span class="in1">in early childhood, <a href="#Page_40">40</a></span><br /> +<br /> +Mental processes, development of, <a href="#Page_5">5</a>, <a href="#Page_22">22</a>, <a href="#Page_23">23</a>, <a href="#Page_50">50</a><br /> +<span class="in1">age at which most apparent, <a href="#Page_16">16</a></span><br /> +<span class="in1">in later childhood, <a href="#Page_117">117</a></span><br /> +<span class="in1">effect of unconscious suggestions on, <a href="#Page_29">29</a></span><br /> +<span class="in1">heredity in relation to, <a href="#Page_10">10</a></span><br /> +<span class="in1">influence of environment on, <a href="#Page_10">10</a>, <a href="#Page_22">22</a></span><br /> +<br /> +Mental training, <a href="#Page_122">122</a><br /> +<span class="in1">compared with physical training, <a href="#Page_120">120</a></span><br /> +<span class="in1">objects and advantages of, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></span><br /> +<br /> +Mental unrest,<br /> +<span class="in1">avoidance of, <a href="#Page_67">67</a></span><br /> +<span class="in1">crying in relation to, <a href="#Page_67">67</a></span><br /> +<span class="in1">digestive disturbances due to, <a href="#Page_62">62</a></span><br /> +<span class="in1">growth of neuroses in atmosphere of, <a href="#Page_75">75</a></span><br /> + +<span class="pagenum">Page 197<a name="Page_197" id="Page_197"></a></span> + +<span class="in1">habitual actions in relation to, <a href="#Page_77">77</a></span><br /> +<span class="in1">in the adult, <a href="#Page_7">7</a></span><br /> +<span class="in1">in the child, <a href="#Page_6">6</a>, <a href="#Page_7">7</a></span><br /> +<span class="in1">negativism due to, <a href="#Page_60">60</a></span><br /> +<span class="in1">of newborn infant, effects of, <a href="#Page_107">107</a></span><br /> +<span class="in1"><i>See also</i> Nervous Unrest</span><br /> +<br /> +Micturition,<br /> +<span class="in1">functional disorder of, <a href="#Page_30">30</a></span><br /> +<span class="in1">negativism in, <a href="#Page_81">81</a></span><br /> +<span class="in1">regulation of, <a href="#Page_30">30</a></span><br /> +<span class="in1"><i>See also</i> Enuresis</span><br /> +<br /> +Migraine,<br /> +<span class="in1">periodic vomiting associated with, <a href="#Page_85">85</a></span><br /> +<span class="in1">symptom of nervous exhaustion, <a href="#Page_87">87</a></span><br /> +<br /> +Mind,<br /> +<span class="in1">and body, development of, <a href="#Page_120">120</a>, <a href="#Page_121">121</a></span><br /> +<span class="in1">effect on the body, <a href="#Page_51">51</a></span><br /> +<span class="in1">vigour of, in relation to that of body, <a href="#Page_120">120</a></span><br /> +<br /> +Money, theft of, <a href="#Page_127">127</a><br /> +<br /> +Montessori system of training, <a href="#Page_20">20</a>, <a href="#Page_23">23</a>, <a href="#Page_121">121</a><br /> +<br /> +Moral degeneracy, <a href="#Page_126">126</a><br /> +<br /> +Moral standard of school life, <a href="#Page_183">183</a><br /> +<br /> +Moral training, <a href="#Page_123">123</a><br /> +<span class="in1">importance and effects of, <a href="#Page_120">120</a></span><br /> +<span class="in1">negative virtues and, <a href="#Page_124">124</a></span><br /> +<span class="in1">objects and advantages of, <a href="#Page_123">123</a>, <a href="#Page_126">126</a></span><br /> +<span class="in1">parents' responsibilities in, <a href="#Page_123">123</a>, <a href="#Page_124">124</a></span><br /> +<br /> +Morals, public opinion forming code of, <a href="#Page_183">183</a><br /> +<br /> +Morbid introspection, <a href="#Page_139">139</a><br /> +<br /> +Mothers,<br /> +<span class="in1">ability and inability to manage children, <a href="#Page_8">8</a></span><br /> +<span class="in1">attitude in regard to temperament of child, <a href="#Page_10">10</a>, 11</span><br /> +<span class="in1">care of, during lactation, <a href="#Page_110">110</a></span><br /> +<span class="in1">conduct of child influenced by, <a href="#Page_11">11</a></span><br /> +<span class="in1">inability to understand nature of child's disorders, <a href="#Page_5">5</a></span><br /> +<span class="in1">influence of, on tone and manner of speech, <a href="#Page_17">17</a></span><br /> +<span class="in1">mental environment of child created by, <a href="#Page_8">8</a></span><br /> +<span class="in1">personality of, <a href="#Page_7">7</a></span><br /> +<span class="in1">relation to the child, <a href="#Page_101">101</a></span><br /> +<br /> +Motionless children, <a href="#Page_157">157</a><br /> +<br /> +Mouth, habit of conveying everything to, cause of, <a href="#Page_19">19</a><br /> +<br /> +Movements,<br /> +<span class="in1">precision of, <a href="#Page_20">20</a></span><br /> +<span class="in1">purposive, development of, <a href="#Page_19">19</a>, <a href="#Page_21">21</a></span><br /> +<span class="in1">self-command of, <a href="#Page_21">21</a></span><br /> +<br /> +Muscular atrophy, and neurosis, <a href="#Page_151">151</a><br /> +<br /> +Muscular system,<br /> +<span class="in1">changes in infantile children, <a href="#Page_148">148</a></span><br /> +<span class="in1">weak development of, <a href="#Page_151">151</a></span><br /> +<br /> +Muscular tone, how improved, <a href="#Page_154">154</a><br /> +<br /> +Myopathy, primary, <a href="#Page_151">151</a><br /> + <br /> +</p> + +<p> +Nasal obstruction<br /> +<span class="in1">and failure of lactation, <a href="#Page_12">12</a>, 108</span><br /> +<span class="in1">night-terrors aggravated by, <a href="#Page_136">136</a></span><br /> +<br /> +Natural history, sexual matters taught by, <a href="#Page_174">174</a><br /> +<br /> +Naughtiness, child's delight in, <a href="#Page_45">45</a><br /> +<br /> +Naughty, use of the term, <a href="#Page_44">44</a><br /> +<br /> +Negative virtues, and moral training, <a href="#Page_124">124</a><br /> +<br /> +Negativism, <a href="#Page_3">3</a>, <a href="#Page_12">12</a>, <a href="#Page_13">13</a><br /> +<span class="in1">cause of, <a href="#Page_60">60</a>, <a href="#Page_61">61</a></span><br /> +<span class="in1">characteristics, <a href="#Page_50">50</a></span><br /> +<span class="in1">factors developing, <a href="#Page_56">56</a></span><br /> +<span class="in1">in constipation, <a href="#Page_80">80</a></span><br /> +<span class="in1">in micturition, <a href="#Page_81">81</a></span><br /> +<span class="in1">spirit of, <a href="#Page_45">45</a></span><br /> +<span class="in1">treatment of, <a href="#Page_60">60</a></span><br /> +<span class="in1">want of sleep depending on, <a href="#Page_64">64</a></span><br /> +<br /> +Nerve centres, controlling movement, development of, <a href="#Page_21">21</a><br /> +<br /> +Nervous control, instability of, connection between bodily ailments<br /> +<span class="in1">and, <a href="#Page_120">120</a></span><br /> +<br /> +Nervous cough, <a href="#Page_73">73</a><br /> +<br /> +Nervous disorders,<br /> +<span class="in1">and psycho-analysis, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<span class="in1">common, causes, characteristics, and treatment, <a href="#Page_140">140</a>-142</span><br /> +<span class="in1">frequency of, <a href="#Page_50">50</a></span><br /> +<br /> +Nervous exhaustion, cyclic vomiting and migraine symptoms of, <a href="#Page_87">87</a><br /> +<br /> +Nervous instability, stigma of, <a href="#Page_140">140</a>-142<br /> + +<span class="pagenum">Page 198<a name="Page_198" id="Page_198"></a></span> + +<br /> +Nervous system, abnormal in children, <a href="#Page_149">149</a><br /> +<span class="in1">in relation to cyclic vomiting, <a href="#Page_85">85</a></span><br /> +<span class="in1">increased irritability of, <a href="#Page_81">81</a></span><br /> +<span class="in1">infantile characteristics of, <a href="#Page_149">149</a></span><br /> +<br /> +Nervous unrest, environment in relation to, <a href="#Page_142">142</a><br /> +<span class="in1">factors increasing, <a href="#Page_61">61</a></span><br /> +<span class="in1">manifestations of, <a href="#Page_73">73</a></span><br /> +<span class="in1">recurrence of periods of, <a href="#Page_61">61</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_6">6</a>, <a href="#Page_7">7</a></span><br /> +<span class="in1"><i>See also</i> Mental Unrest</span><br /> +<br /> +Nervous vomiting. <i>See</i> Vomiting<br /> +<br /> +Nervousness, and digestive disorders, <a href="#Page_53">53</a>, <a href="#Page_54">54</a><br /> +<span class="in1">and neuropathy, <a href="#Page_132">132</a>-135</span><br /> +<span class="in1">in early infancy, <a href="#Page_104">104</a></span><br /> +<span class="in1">in older children, <a href="#Page_131">131</a>-144</span><br /> +<span class="in1">parents' attitude causing, <a href="#Page_31">31</a></span><br /> +<br /> +Nettlerash, <a href="#Page_161">161</a><br /> +<br /> +Neurasthenia, <a href="#Page_157">157</a><br /> +<br /> +Neuropathic children, common symptoms of, <a href="#Page_140">140</a>-144<br /> +<span class="in1">conduct of, <a href="#Page_133">133</a></span><br /> +<span class="in1">faulty contact with environment in, <a href="#Page_138">138</a></span><br /> +<span class="in1">fear the prominent symptom of, <a href="#Page_133">133</a></span><br /> +<span class="in1">introspection and self-consciousness of, <a href="#Page_138">138</a></span><br /> +<span class="in1">management of, <a href="#Page_150">150</a></span><br /> +<span class="in1">training of, <a href="#Page_126">126</a></span><br /> +<br /> +Neuropathic tendencies, evidence of, in older children, <a href="#Page_133">133</a><br /> +<br /> +Neuropaths, adult, <a href="#Page_143">143</a><br /> +<span class="in1">faulty management in child life leading to, <a href="#Page_2">2</a>, <a href="#Page_14">14</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_132">132</a></span><br /> +<span class="in1">phobias of, <a href="#Page_143">143</a></span><br /> +<span class="in1">selection of suitable environment for, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_7">7</a></span><br /> +<br /> +Neuroses, and psycho-analysis, <a href="#Page_177">177</a>, <a href="#Page_180">180</a><br /> +<span class="in1">association of albuminuria with, <a href="#Page_153">153</a></span><br /> +<span class="in1">constipation frequently due to, <a href="#Page_80">80</a></span><br /> +<span class="in1">examination of, <a href="#Page_82">82</a></span><br /> +<span class="in1">growth in atmosphere of unrest and apprehension, <a href="#Page_75">75</a></span><br /> +<span class="in1">relation of, to infection of the body, <a href="#Page_167">167</a></span><br /> +<span class="in1">treatment of, <a href="#Page_153">153</a></span><br /> +<br /> +Neurotics, and physique, <a href="#Page_145">145</a>, <a href="#Page_151">151</a><br /> +<span class="in1">characteristics, <a href="#Page_131">131</a>, <a href="#Page_132">132</a></span><br /> +<span class="in1">exaggeration of emotions of, <a href="#Page_131">131</a></span><br /> +<br /> +Newborn baby, administration of sedatives to, <a href="#Page_110">110</a><br /> +<span class="in1">artificial feeding of, <a href="#Page_109">109</a>, <a href="#Page_113">113</a></span><br /> +<span class="in1">breast feeding of, <a href="#Page_106">106</a>, <a href="#Page_107">107</a></span><br /> +<span class="in1">case of, <a href="#Page_105">105</a>, <a href="#Page_109">109</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a></span><br /> +<span class="in1">effect of mental unrest on, <a href="#Page_107">107</a></span><br /> +<span class="in1">first impressions of, <a href="#Page_104">104</a></span><br /> +<span class="in1">formation of habits of sleep and crying in, <a href="#Page_115">115</a></span><br /> +<span class="in1">heat and cold in relation to, <a href="#Page_106">106</a></span><br /> +<span class="in1">hunger of, <a href="#Page_105">105</a>, <a href="#Page_109">109</a></span><br /> +<span class="in1">induction of the sucking movements of, <a href="#Page_106">106</a></span><br /> +<span class="in1">of nervous inheritance, <a href="#Page_105">105</a></span><br /> +<span class="in1">personality of, <a href="#Page_104">104</a></span><br /> +<span class="in1">prevention of restlessness and crying, <a href="#Page_114">114</a>, <a href="#Page_115">115</a></span><br /> +<span class="in1">reduction of sense stimuli in, <a href="#Page_105">105</a></span><br /> +<span class="in1">reflex action of sucking in, <a href="#Page_108">108</a></span><br /> +<span class="in1">sense of taste of, <a href="#Page_113">113</a></span><br /> +<span class="in1">symptoms of dyspepsia in, <a href="#Page_116">116</a></span><br /> +<span class="in1">times of feeding, <a href="#Page_116">116</a></span><br /> +<span class="in1">weaning of, <a href="#Page_113">113</a>, <a href="#Page_114">114</a></span><br /> +<br /> +Night-terrors, aggravation of, <a href="#Page_70">70</a>, <a href="#Page_136">136</a><br /> +<span class="in1">causes of, <a href="#Page_135">135</a></span><br /> +<span class="in1">of neuropathic children, <a href="#Page_134">134</a></span><br /> +<br /> +Nursery, activities in, child's interest in, <a href="#Page_22">22</a>-23<br /> +<span class="in1">importance of child's being alone</span><br /> +<span class="in1">in, <a href="#Page_36">36</a>, <a href="#Page_38">38</a>, <a href="#Page_96">96</a>, <a href="#Page_99">99</a>, <a href="#Page_101">101</a></span><br /> +<span class="in1">observations in, <a href="#Page_16">16</a></span><br /> +<br /> +Nursery life, advantages of, <a href="#Page_9">9</a><br /> +<br /> +Nursery psycho-therapeutics, <a href="#Page_15">15</a><br /> +<br /> +Nurses, ability and inability to manage children, <a href="#Page_9">9</a><br /> +<span class="in1">influence of, on tone and manner of speech, <a href="#Page_17">17</a></span><br /> +<span class="in1">mental environment of child created by, <a href="#Page_8">8</a></span><br /> +<span class="in1">personality of, <a href="#Page_7">7</a></span><br /> +<br /> +Nursing, during sickness, <a href="#Page_166">166</a><br /> +<span class="in1">of the newborn infant, <a href="#Page_105">105</a>-115</span><br /> + <br /> +</p> + +<p><span class="pagenum">Page 199<a name="Page_199" id="Page_199"></a></span></p> + +<p>Obedience, <a href="#Page_49">49</a><br /> +<span class="in1">and perverse pleasure, <a href="#Page_34">34</a></span><br /> +<span class="in1">growth of, <a href="#Page_42">42</a></span><br /> +<br /> +Obsession of bed wetting, <a href="#Page_89">89</a>, <a href="#Page_91">91</a><br /> +<br /> +Opposition, <a href="#Page_61">61</a><br /> +<span class="in1">and counter-opposition, <a href="#Page_67">67</a>, <a href="#Page_179">179</a></span><br /> +<span class="in1">during sickness, <a href="#Page_160">160</a></span><br /> +<span class="in1">force of, factors influencing development, <a href="#Page_60">60</a></span><br /> +<span class="in1">habit of, <a href="#Page_59">59</a></span><br /> +<span class="in1">impulse of, <a href="#Page_35">35</a></span><br /> +<span class="in1">love of, in early childhood, <a href="#Page_59">59</a>, <a href="#Page_60">60</a></span><br /> +<span class="in1">to food, <a href="#Page_25">25</a></span><br /> +<br /> +Organic disturbance, in combination with functional trouble, <a href="#Page_4">4</a><br /> + <br /></p> + +<p>Pain, frequent loss of sense of, in neuropaths, <a href="#Page_138">138</a>, <a href="#Page_139">139</a><br /> +<br /> +Pallor, <a href="#Page_152">152</a><br /> +<span class="in1">sudden attacks of, <a href="#Page_141">141</a></span><br /> +<br /> +Palpitation, example of visceral fatigue, <a href="#Page_143">143</a><br /> +<br /> +Parathyroid glands, function of, <a href="#Page_147">147</a><br /> +<br /> +Parents,<br /> +<span class="in1">and children, conflict between, <a href="#Page_43">43</a>, <a href="#Page_44">44</a></span><br /> +<span class="in1">and silence on sexual matters, <a href="#Page_170">170</a></span><br /> +<span class="in1">habitual actions of, reproduced in the child, <a href="#Page_75">75</a></span><br /> +<span class="in1">mental attitude of, in relation to conduct, <a href="#Page_31">31</a></span><br /> +<span class="in1">over-exercise of authority by, results of, <a href="#Page_42">42</a>, <a href="#Page_43">43</a>, <a href="#Page_45">45</a></span><br /> +<span class="in1">responsibilities in moral training of child, <a href="#Page_123">123</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">suggestions unconsciously conveyed by, evil results of, <a href="#Page_31">31</a>, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<br /> +Parties, disadvantages of, <a href="#Page_102">102</a><br /> +<br /> +Patient, temperament of, physician in relation to, <a href="#Page_4">4</a><br /> +<br /> +Pelvis, development of, <a href="#Page_146">146</a><br /> +<br /> +Peripheral nerves, increase in irritability and conductivity of, <a href="#Page_81">81</a><br /> +<br /> +Personal adornment, delight in, <a href="#Page_48">48</a><br /> +<br /> +Personality,<br /> +<span class="in1">and disobedience, <a href="#Page_58">58</a></span><br /> +<span class="in1">child's own conception of, <a href="#Page_24">24</a>, <a href="#Page_129">129</a></span><br /> +<span class="in1">environment influencing, <a href="#Page_25">25</a></span><br /> +<span class="in1">in early childhood, <a href="#Page_32">32</a>, <a href="#Page_165">165</a></span><br /> +<span class="in1">of newborn baby, <a href="#Page_104">104</a></span><br /> +<br /> +Perspiration, abundant, sudden attacks of, <a href="#Page_141">141</a><br /> +<br /> +Phobias, 14<br /> +<span class="in1">characteristics and varieties, <a href="#Page_134">134</a>, <a href="#Page_135">135</a></span><br /> +<span class="in1">frequency of, <a href="#Page_134">134</a></span><br /> +<span class="in1">treatment of, <a href="#Page_135">135</a></span><br /> +<br /> +Physical defects, accompanying neurosis, <a href="#Page_145">145</a>, <a href="#Page_151">151</a><br /> +<br /> +Physical disturbances, due to emotion, <a href="#Page_53">53</a>, <a href="#Page_54">54</a><br /> +<br /> +Physical exercise, lack of, causing want of sleep, <a href="#Page_69">69</a><br /> +<br /> +Physical fatigue, easily produced in nervous children, <a href="#Page_143">143</a><br /> +<br /> +Physical phenomena of neuropaths, <a href="#Page_132">132</a><br /> +<br /> +Physical training, <a href="#Page_121">121</a><br /> +<span class="in1">objects and advantages of, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></span><br /> +<br /> +Physician,<br /> +<span class="in1">and the temperament of his patient, <a href="#Page_4">4</a></span><br /> +<span class="in1">examination by, <a href="#Page_2">2</a>, <a href="#Page_3">3</a>, <a href="#Page_13">13</a></span><br /> +<span class="in1">diagnosis by, <a href="#Page_2">2</a>, <a href="#Page_3">3</a>, <a href="#Page_13">13</a></span><br /> +<span class="in1">difficulties of, <a href="#Page_4">4</a></span><br /> +<br /> +Physique, intellect compared with, <a href="#Page_120">120</a><br /> +<br /> +Pica and dirt eating, <a href="#Page_80">80</a><br /> +<br /> +Picture books,<br /> +<span class="in1">educative value of, <a href="#Page_100">100</a></span><br /> +<span class="in1">kinds most suitable, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<br /> +Play,<br /> +<span class="in1">happiness of child during, <a href="#Page_96">96</a></span><br /> +<span class="in1">in the nursery, <a href="#Page_36">36</a>, <a href="#Page_37">37</a></span><br /> +<span class="in1">with grown-up persons, <a href="#Page_36">36</a>, <a href="#Page_38">38</a></span><br /> +<br /> +Pleasure, sense of, in early childhood, <a href="#Page_48">48</a><br /> +<br /> +Polarisation of ideas, <a href="#Page_172">172</a><br /> +<br /> +Postural albuminuria, <a href="#Page_152">152</a><br /> +<br /> +Posture, faulty, <a href="#Page_161">161</a>, <a href="#Page_162">162</a><br /> +<span class="in2">prevention of, <a href="#Page_154">154</a></span><br /> +<br /> +Power, child's love of, <a href="#Page_32">32</a>, <a href="#Page_59">59</a><br /> +<br /> +Precision of movement, development of, <a href="#Page_19">19</a>, <a href="#Page_96">96</a><br /> +<br /> +Psycho-analysis,<br /> +<span class="in1">dangers of, <a href="#Page_180">180</a></span><br /> +<span class="in1">observations on, <a href="#Page_176">176</a>, <a href="#Page_177">177</a></span><br /> +<br /> +Public schools, character and effects of, <a href="#Page_183">183</a><br /> + +<span class="pagenum">Page 200<a name="Page_200" id="Page_200"></a></span> + +<br /> +Punishment,<br /> +<span class="in1">deserved and undeserved, <a href="#Page_126">126</a></span><br /> +<span class="in1">frequent, disadvantages of, <a href="#Page_47">47</a></span><br /> +<span class="in1">observations on, <a href="#Page_39">39</a>, <a href="#Page_46">46</a></span><br /> +<br /> +Purity, inculcation of high ideals of, <a href="#Page_175">175</a><br /> +<br /> +Purposive movements, earliest,<br /> +<span class="in1">cause of, <a href="#Page_19">19</a></span><br /> +<span class="in1">encouragement of, <a href="#Page_24">24</a></span><br /> +<br /> +Pyloric spasm, <a href="#Page_112">112</a><br /> +<br /> +Pyrexia, <a href="#Page_88">88</a><br /> +<span class="in1">organic disease in relation to, <a href="#Page_88">88</a></span><br /> + <br /></p> + +<p> +Rational hygiene, <a href="#Page_5">5</a><br /> +<br /> +Reasoning power, <a href="#Page_40">40</a><br /> +<span class="in1">active before advent of speech, <a href="#Page_40">40</a></span><br /> +<span class="in1">factors influencing development of, <a href="#Page_40">40</a>, <a href="#Page_41">41</a>, <a href="#Page_117">117</a>, <a href="#Page_118">118</a></span><br /> +<br /> +Regulation of habits, <a href="#Page_30">30</a><br /> +<br /> +Repression, by older children of younger, <a href="#Page_47">47</a><br /> +<br /> +Reproduction, method of imparting knowledge of, <a href="#Page_174">174</a><br /> +<br /> +Reproof, <a href="#Page_20">20</a>, <a href="#Page_21">21</a>, <a href="#Page_24">24</a><br /> +<span class="in1">cases in which useless, <a href="#Page_60">60</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">causing disobedience, <a href="#Page_61">61</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">effects of, <a href="#Page_33">33</a>, <a href="#Page_36">36</a>, <a href="#Page_47">47</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">extreme sensitiveness to, 46</span><br /> +<span class="in1">perverse pleasure of, <a href="#Page_34">34</a></span><br /> +<span class="in1">too frequent repetition of, futility of, <a href="#Page_44">44</a>, <a href="#Page_45">45</a>, <a href="#Page_47">47</a>, <a href="#Page_60">60</a>, <a href="#Page_124">124</a>, <a href="#Page_125">125</a></span><br /> +<br /> +Restlessness, during sickness, <a href="#Page_160">160</a><br /> +<br /> +Rewards, use and dangers of, <a href="#Page_48">48</a><br /> +<br /> +Rheumatism, <a href="#Page_155">155</a><br /> +<span class="in1">and chorea, association between, <a href="#Page_155">155</a></span><br /> +<span class="in1">characteristics in childhood, <a href="#Page_156">156</a></span><br /> +<span class="in1">subacute, <a href="#Page_167">167</a></span><br /> +<span class="in1">treatment of, <a href="#Page_156">156</a></span><br /> +<br /> +Rickets,<br /> +<span class="in1">mental and intellectual condition in, <a href="#Page_120">120</a></span><br /> +<span class="in1">in infantile children, <a href="#Page_148">148</a></span><br /> +<span class="in1">occurrence with spasmophilia, <a href="#Page_82">82</a></span><br /> +<br /> +Right and wrong, appreciation of, in early childhood, <a href="#Page_42">42</a><br /> +<br /> +Round shoulders, <a href="#Page_151">151</a><br /> + <br /></p> + +<p> +St. Vitus's dance, <a href="#Page_167">167</a><br /> +<br /> +Salts, excretion of, <a href="#Page_147">147</a><br /> +<br /> +School life, <a href="#Page_182">182</a>, <a href="#Page_184">184</a><br /> +<span class="in1">and sexual matters, <a href="#Page_171">171</a>, <a href="#Page_175">175</a></span><br /> +<span class="in1">moral standard of, <a href="#Page_183">183</a></span><br /> +<span class="in1">moral training and, <a href="#Page_123">123</a></span><br /> +<span class="in1">moulding of character during, <a href="#Page_184">184</a></span><br /> +<span class="in1">of boys, <a href="#Page_183">183</a>-187</span><br /> +<span class="in1">of girls, <a href="#Page_188">188</a></span><br /> +<br /> +Schools, public, character and effects of, <a href="#Page_183">183</a><br /> +<br /> +Scoliosis, prevention of, <a href="#Page_154">154</a><br /> +<br /> +Secretions, anomalies of, <a href="#Page_141">141</a><br /> +<br /> +Self, child's conception of, <a href="#Page_48">48</a><br /> +<br /> +Self-conscious children, complaints of, <a href="#Page_139">139</a><br /> +<br /> +Self-consciousness, of neuropathic children, <a href="#Page_138">138</a><br /> +<br /> +Self-discipline, development of, <a href="#Page_125">125</a>, <a href="#Page_126">126</a><br /> +<br /> +Self-education, in the nursery, <a href="#Page_96">96</a><br /> +<br /> +Self-feeding, <a href="#Page_55">55</a><br /> +<br /> +Self-preservation, morbid instinct of, <a href="#Page_134">134</a><br /> +<br /> +Self-sacrifice, not to be expected in early childhood, <a href="#Page_48">48</a>-49<br /> +<br /> +Sensations,<br /> +<span class="in1">acuteness of, <a href="#Page_69">69</a></span><br /> +<span class="in1">bodily, of neuropaths, <a href="#Page_138">138</a></span><br /> +<br /> +Sense perception, of neuropaths, <a href="#Page_132">132</a><br /> +<br /> +Sense stimuli,<br /> +<span class="in1">cultivation of perception of, <a href="#Page_23">23</a></span><br /> +<span class="in1">in newborn babies, <a href="#Page_105">105</a></span><br /> +<br /> +Sexual matters,<br /> +<span class="in1">education on, <a href="#Page_168">168</a></span><br /> +<span class="in1">method of, <a href="#Page_174">174</a></span><br /> +<span class="in1">errors of conduct and, <a href="#Page_176">176</a></span><br /> +<span class="in1">parents' silence in regard to, <a href="#Page_170">170</a></span><br /> +<span class="in1">psycho-analysis in relation to, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<span class="in1">school life in relation to, <a href="#Page_171">171</a>, <a href="#Page_175">175</a></span><br /> +<br /> +Sickness, <a href="#Page_160">160</a><br /> +<span class="in1">evil effects of suggestions unconsciously conveyed by parents</span><br /> +<span class="in2">during, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<span class="in1">management during, <a href="#Page_160">160</a>, <a href="#Page_163">163</a></span><br /> +<span class="in1">nurse and mother during, <a href="#Page_166">166</a></span><br /> +<span class="in1">opposition during, <a href="#Page_160">160</a></span><br /> +<span class="in1">temperature during, <a href="#Page_161">161</a></span><br /> +<span class="in1">therapeutic measures in, <a href="#Page_164">164</a></span><br /> +<span class="in1">therapeutic procedures concentrating child's mind on his symptoms, <a href="#Page_163">163</a></span><br /> + +<span class="pagenum">Page 201<a name="Page_201" id="Page_201"></a></span> + +<br /> +Sleep, estimation of the amount of, <a href="#Page_136">136</a><br /> +<span class="in1">force of suggestion in relation to, <a href="#Page_27">27</a>, <a href="#Page_28">28</a></span><br /> +<span class="in1">formation of habit of, <a href="#Page_115">115</a></span><br /> +<span class="in1">light and broken, cause of, <a href="#Page_68">68</a>, <a href="#Page_136">136</a>, <a href="#Page_137">137</a></span><br /> +<span class="in2">of newborn infant, <a href="#Page_114">114</a></span><br /> +<span class="in1">sound, beneficial effects of, <a href="#Page_71">71</a></span><br /> +<br /> +Sleeping attire, <a href="#Page_69">69</a><br /> +<br /> +Sleeplessness, breaking of the habit of, <a href="#Page_70">70</a><br /> +<span class="in1">causes and characteristics, <a href="#Page_64">64</a></span><br /> +<span class="in1">drugs in, <a href="#Page_70">70</a>, <a href="#Page_71">71</a></span><br /> +<span class="in1">in older children, <a href="#Page_136">136</a></span><br /> +<span class="in1">lack of physical exercise causing, <a href="#Page_69">69</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_27">27</a>, <a href="#Page_28">28</a>, <a href="#Page_70">70</a></span><br /> +<span class="in1">treatment of, <a href="#Page_67">67</a>, <a href="#Page_70">70</a>, <a href="#Page_137">137</a></span><br /> +<br /> +Sleep-walking, <a href="#Page_137">137</a><br /> +<br /> +Snatching, habit of, <a href="#Page_20">20</a><br /> +<br /> +Spasmophilia, <a href="#Page_81">81</a><br /> +<span class="in1">ætiology of, <a href="#Page_81">81</a></span><br /> +<span class="in1">drugs in treatment of, <a href="#Page_84">84</a></span><br /> +<span class="in1">occurrence of rickets with, <a href="#Page_82">82</a></span><br /> +<br /> +Spasms, control of, <a href="#Page_84">84</a><br /> +<span class="in1">fatal, <a href="#Page_83">83</a></span><br /> +<br /> +Speech, beginnings of, <a href="#Page_17">17</a>, <a href="#Page_18">18</a><br /> +<span class="in1">facility with which local accent is acquired, <a href="#Page_17">17</a></span><br /> +<span class="in1">imitativeness of, <a href="#Page_17">17</a>, <a href="#Page_18">18</a></span><br /> +<span class="in1">infant's reasoning power present before advent of, <a href="#Page_40">40</a></span><br /> +<span class="in1">influence of nurses and mothers on tone and manner of, <a href="#Page_17">17</a></span><br /> +<br /> +Spinal deformity, prevention of, <a href="#Page_154">154</a><br /> +<br /> +Spinal muscles, atrophy of, <a href="#Page_151">151</a><br /> +<br /> +Spoon feeding, <a href="#Page_113">113</a><br /> +<br /> +Status catarrhalis, <a href="#Page_150">150</a><br /> +<br /> +Status lymphaticus, <a href="#Page_150">150</a><br /> +<br /> +Story-telling, <a href="#Page_99">99</a>, <a href="#Page_100">100</a><br /> +<br /> +Sucking movements, of newborn child, induction of, <a href="#Page_106">106</a><br /> +<span class="in1"><i>see also</i> Lactation</span><br /> +<br /> +Suggestion, and habit spasms, <a href="#Page_74">74</a><br /> +<span class="in1">appetite in relation to, <a href="#Page_52">52</a></span><br /> +<span class="in1">bed wetting in relation to, <a href="#Page_89">89</a></span><br /> +<span class="in1">bodily habits in relation to, <a href="#Page_30">30</a></span><br /> +<span class="in1">characteristics, <a href="#Page_24">24</a></span><br /> +<span class="in1">conduct influenced by, <a href="#Page_13">13</a>, <a href="#Page_130">130</a></span><br /> +<span class="in1">constipation in relation to, <a href="#Page_80">80</a></span><br /> +<span class="in1">effect on mental processes, <a href="#Page_29">29</a></span><br /> +<span class="in1">food in relation to, <a href="#Page_25">25</a></span><br /> +<span class="in1">force of, on child's mind, <a href="#Page_27">27</a>, <a href="#Page_75">75</a></span><br /> +<span class="in1">hysteria in relation to, <a href="#Page_32">32</a></span><br /> +<span class="in1">perverse influence of, <a href="#Page_29">29</a>, <a href="#Page_30">30</a></span><br /> +<span class="in2">bad habits due to, <a href="#Page_89">89</a>, <a href="#Page_90">90</a></span><br /> +<span class="in2">causing constipation, <a href="#Page_30">30</a></span><br /> +<span class="in2">want of sleep depending upon, <a href="#Page_64">64</a></span><br /> +<span class="in1">refusal of food in relation to, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in1">sleep in relation to, <a href="#Page_27">27</a></span><br /> +<span class="in1">susceptibility to, <a href="#Page_29">29</a>, <a href="#Page_57">57</a></span><br /> +<span class="in1">unconsciously conveyed by parents, evil results of, <a href="#Page_31">31</a>, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<br /> +Suicide, <a href="#Page_52">52</a><br /> +<br /> +Suspicions, aroused in the child, <a href="#Page_57">57</a>, <a href="#Page_58">58</a><br /> +<br /> +Syncopal attacks, causes and characteristics, <a href="#Page_140">140</a>, <a href="#Page_141">141</a><br /> + <br /></p> + +<p> +Tactile sensation. <i>See</i> Touch<br /> +<br /> +Taste, perversion of, <a href="#Page_26">26</a>, <a href="#Page_57">57</a><br /> +<span class="in1">sensations of, <a href="#Page_25">25</a></span><br /> +<span class="in2">how controlled, <a href="#Page_26">26</a></span><br /> +<span class="in1">sense of, in newborn infant, <a href="#Page_113">113</a></span><br /> +<br /> +Teething convulsions, <a href="#Page_148">148</a><br /> +<br /> +Tell-tale child, characteristics, <a href="#Page_18">18</a><br /> +<br /> +Temperament, diversity of, <a href="#Page_10">10</a><br /> +<span class="in1">heredity and, <a href="#Page_10">10</a></span><br /> +<span class="in1">mother's attitude in relation to, <a href="#Page_10">10</a>, <a href="#Page_11">11</a></span><br /> +<span class="in1">of the patient, physician in relation to, <a href="#Page_4">4</a></span><br /> +<br /> +Temperature, during sickness, <a href="#Page_161">161</a><br /> +<span class="in1">inexplicable rises in, <a href="#Page_88">88</a></span><br /> +<br /> +Terror, causes, of, <a href="#Page_28">28</a><br /> +<br /> +Tetany, liability to, in increased irritability of nervous system, <a href="#Page_81">81</a><br /> +<span class="in1">pressure to brachial nerve causing, <a href="#Page_81">81</a></span><br /> +<br /> +Theatres, disadvantages of, <a href="#Page_103">103</a><br /> +<br /> +Theft, <a href="#Page_52">52</a>, <a href="#Page_127">127</a><br /> +<br /> +Therapeutic conversation, <a href="#Page_124">124</a>, <a href="#Page_125">125</a><br /> + +<span class="pagenum">Page 202<a name="Page_202" id="Page_202"></a></span> + +<br /> +Thigh rubbing,<br /> +<span class="in1">avoidance of, <a href="#Page_78">78</a></span><br /> +<span class="in1">characteristics, <a href="#Page_78">78</a></span><br /> +<span class="in1">habitual action of, <a href="#Page_78">78</a></span><br /> +<br /> +Thorax, development of, <a href="#Page_146">146</a><br /> +<br /> +Thumb sucking, <a href="#Page_78">78</a>, <a href="#Page_79">79</a><br /> +<span class="in1">persistence of the habit, <a href="#Page_79">79</a></span><br /> +<br /> +Tongue-tie, in relation to lactation, <a href="#Page_12">12</a><br /> +<br /> +Tonics, <a href="#Page_155">155</a><br /> +<br /> +Tonsils, removal of, in treatment of enuresis, <a href="#Page_93">93</a><br /> +<br /> +Touch, sense of,<br /> +<span class="in1">cultivation of, <a href="#Page_23">23</a></span><br /> +<span class="in1">early development of, <a href="#Page_19">19</a>, <a href="#Page_20">20</a></span><br /> +<span class="in1">organs with greatest development of, <a href="#Page_19">19</a></span><br /> +<br /> +Toys,<br /> +<span class="in1">child's interest in, <a href="#Page_36">36</a></span><br /> +<span class="in1">educative value of, <a href="#Page_96">96</a>, <a href="#Page_98">98</a></span><br /> +<span class="in1">kind most suitable, <a href="#Page_97">97</a></span><br /> +<br /> +Training, early, importance and object of, <a href="#Page_2">2</a><br /> +<br /> +Trousseau's sign, nature and production of, <a href="#Page_81">81</a><br /> +<br /> +Truthfulness, <a href="#Page_123">123</a>, <a href="#Page_124">124</a><br /> +<span class="in1">inculcation of, <a href="#Page_128">128</a></span><br /> +<br /> +Twitching of facial muscles, <a href="#Page_81">81</a>, <a href="#Page_83">83</a><br /> +<br /> +Tyranny of tears, <a href="#Page_116">116</a><br /> + <br /></p> + +<p>Unkindness, habitual, of children to others, <a href="#Page_129">129</a><br /> +<br /> +Untruthfulness, <a href="#Page_126">126</a><br /> +<span class="in1">over-exercise of authority encouraging, <a href="#Page_43">43</a></span><br /> +<br /> +Urine,<br /> +<span class="in1">condition in enuresis, <a href="#Page_93">93</a></span><br /> +<span class="in1">incontinence of, methods of treatment, <a href="#Page_92">92</a>, <a href="#Page_93">93</a></span><br /> +<span class="in2"><i>See also</i> Enuresis</span><br /> +<span class="in1">increased secretion of, <a href="#Page_141">141</a></span><br /> +<span class="in1">irritation of, <a href="#Page_148">148</a></span><br /> + <br /></p> + +<p>Vasomotor instability,<br /> +<span class="in1">conditions indicating, <a href="#Page_140">140</a>, <a href="#Page_141">141</a></span><br /> +<span class="in1">in neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Vasomotor tone, how improved, <a href="#Page_154">154</a><br /> +<br /> +Virtuous, definition of the term, <a href="#Page_183">183</a><br /> +<br /> +Visceral fatigue, easily produced in nervous children, <a href="#Page_143">143</a><br /> +<br /> +Vocabulary, <a href="#Page_18">18</a><br /> +<br /> +Voice, tone of, <a href="#Page_17">17</a><br /> +<br /> +Voluntary movements, development of cerebral centres controlling, <a href="#Page_19">19</a><br /> +<br /> +Vomiting, cyclic, <a href="#Page_50">50</a>, <a href="#Page_55">55</a><br /> +<span class="in1">ætiology of, <a href="#Page_85">85</a></span><br /> +<span class="in1">age at which it occurs, <a href="#Page_86">86</a></span><br /> +<span class="in1">case illustrating, <a href="#Page_51">51</a></span><br /> +<span class="in1">causes and characteristics, <a href="#Page_62">62</a>, <a href="#Page_86">86</a></span><br /> +<span class="in1">class of child affected by, <a href="#Page_87">87</a></span><br /> +<span class="in1">condition of the child during, <a href="#Page_86">86</a></span><br /> +<span class="in1">frequency of attacks, <a href="#Page_86">86</a></span><br /> +<span class="in1">migraine in association with, <a href="#Page_85">85</a></span><br /> +<span class="in1">nervous system in relation to, <a href="#Page_85">85</a>, <a href="#Page_87">87</a></span><br /> +<span class="in1">treatment of, <a href="#Page_62">62</a>, <a href="#Page_63">63</a>, <a href="#Page_87">87</a></span><br /> + <br /></p> + +<p> +Waking states, <a href="#Page_136">136</a><br /> +<br /> +Weaning, difficulty in, <a href="#Page_113">113</a>, <a href="#Page_114">114</a><br /> +<br /> +Will, strength of, absence in childhood, <a href="#Page_34">34</a><br /> +<br /> +Work and play, differentiation between, <a href="#Page_123">123</a><br /> +<br /> +Writing, correct posture during, <a href="#Page_155">155</a><br /> +</p> +<p> </p> + +<hr /> + +<p> +Transcriber's Notes<br /> +<br /> +The following typographical errors were corrected:<br /> +Page 4: 'sensisive' changed to 'sensitive'.<br /> +Page 48: 'self-abnegnation' changed to 'self-abnegation'.<br /> +Page 61: fixed 'and and'.<br /> +Page 125: 'acount' changed to 'account'.<br /> +First page of index (191): 'ullimentary' changed to 'Allimentary';<br /> + also 'ilstrating' channged to 'illustrating'.<br /> +</p> + +<div>*** END OF THE PROJECT GUTENBERG EBOOK 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Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..9bddb09 --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #14515 (https://www.gutenberg.org/ebooks/14515) diff --git a/old/14515-8.txt b/old/14515-8.txt new file mode 100644 index 0000000..99af85d --- /dev/null +++ b/old/14515-8.txt @@ -0,0 +1,6401 @@ +The Project Gutenberg EBook of The Nervous Child, by Hector Charles Cameron + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: The Nervous Child + +Author: Hector Charles Cameron + +Release Date: December 29, 2004 [EBook #14515] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK THE NERVOUS CHILD *** + + + + +Produced by Audrey Longhurst, Ronald Holder and the PG Online +Distributed Proofreading Team + + + + + + +THE NERVOUS CHILD + + + + +PUBLISHED BY THE JOINT COMMITTEE OF +HENRY FROWDE, HODDER & STOUGHTON +17 WARWICK SQUARE, LONDON, E.C. 4 + + + + +THE + +NERVOUS CHILD + + +BY + +HECTOR CHARLES CAMERON +M.A., M.D.(CANTAB.), F.R.C.P.(LOND.) +PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF +THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL + + + "RESPECT the child. Be not too much his parent. Trespass not on + his solitude."--EMERSON. + + +LONDON +HENRY FROWDE HODDER & STOUGHTON +OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C. +1920 + + + + +_First Edition_ 1919 +_Second Impression_ 1930 + + + + +PRINTED IN GREAT BRITAIN +BY MORRISON & GIBB LTD., EDINBURGH + + + + +PREFACE + + +To-day on all sides we hear of the extreme importance of Preventive +Medicine and the great future which lies before us in this aspect of +our work. If so, it follows that the study of infancy and childhood +must rise into corresponding prominence. More and more a considerable +part of the Profession must busy itself in nurseries and in schools, +seeking to apply there the teachings of Psychology, Physiology, +Heredity, and Hygiene. To work of this kind, in some of its aspects, +this book may serve as an introduction. It deals with the influences +which mould the mentality of the child and shape his conduct. Extreme +susceptibility to these influences is the mark of the nervous child. + +I have to thank the Editors of _The Practitioner_ and of _The Child_, +respectively, for permission to reprint the chapters which deal with +"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I +should also like to offer thanks for helpful suggestions. + +H.C.C. + +_March_ 1919. + + + + +CONTENTS + +CHAP. PAGE + + I. DOCTORS, MOTHERS, AND CHILDREN 1 + + II. OBSERVATIONS IN THE NURSERY 16 + + III. WANT OF APPETITE AND INDIGESTION 50 + + IV. WANT OF SLEEP 64 + + V. SOME OTHER SIGNS OF NERVOUSNESS 73 + + VI. ENURESIS 89 + + VII. TOYS, BOOKS, AND AMUSEMENTS 96 + +VIII. NERVOUSNESS IN EARLY INFANCY 104 + + IX. MANAGEMENT IN LATER CHILDHOOD 117 + + X. NERVOUSNESS IN OLDER CHILDREN 131 + + XI. NERVOUSNESS AND PHYSIQUE 145 + + XII. THE NERVOUS CHILD IN SICKNESS 160 + +XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS 169 + + XIV. THE NERVOUS CHILD AND SCHOOL 182 + + INDEX 191 + + + + +THE NERVOUS CHILD + +CHAPTER I + +DOCTORS, MOTHERS, AND CHILDREN + + +There is an old fairy story concerning a pea which a princess once +slept upon--a little offending pea, a minute disturbance, a trifling +departure from the normal which grew to the proportions of intolerable +suffering because of the too sensitive and undisciplined nervous +system of Her Royal Highness. The story, I think, does not tell us +much else concerning the princess. It does not tell us, for instance, +if she was an only child, the sole preoccupation of her parents and +nurses, surrounded by the most anxious care, reared with some +difficulty because of her extraordinary "delicacy," suffering from a +variety of illnesses which somehow always seemed to puzzle the +doctors, though some of the symptoms--the vomiting, for example, and +the high temperature--were very severe and persistent. Nor does it +tell us if later in life, but before the suffering from the pea arose, +she had been taken to consult two famous doctors, one of whom had +removed the vermiform appendix, while the other a little later had +performed an operation for "adhesions." At any rate, the story with +these later additions, which are at least in keeping with what we know +of her history, would serve to indicate the importance which attaches +to the early training of childhood. Among the children even of the +well-to-do often enough the hygiene of the mind is overlooked, and +faulty management produces restlessness, instability, and +hyper-sensitiveness, which pass insensibly into neuropathy in adult +life. + +To prevent so distressing a result is our aim in the training of +children. No doubt the matter concerns in the first place parents and +nurses, school masters and mistresses, as well as medical men. Yet +because of the certainty that physical disturbances of one sort or +another will follow upon nervous unrest, it will seldom happen that +medical advice will not be sought sooner or later; and if the +physician is to intervene with success, he must be prepared with +knowledge of many sorts. He must be prepared to make a thorough and +complete physical examination, sufficient to exclude the presence of +organic disease. If no organic disease is found, he must explore the +whole environment of the child, and seek to determine whether the +exciting cause is to be found in the reaction of the child to some +form of faulty management. + +For example, a child of two or three years of age may be brought to +the doctor with the complaint that defæcation is painful, and that +there has existed for some time a most distressing constipation which +has resisted a large number of purgatives of increasing strength. +Whenever the child is placed upon the stool, his crying at once +begins, and no attempts to soothe or console him have been successful. +It is not sufficient for the doctor in such a case to make an +examination which convinces him that there is no fissure at the anus +and no fistula or thrombosed pile, and to confine himself to saying +that he can find nothing the matter. The crying and refusal to go to +stool will continue after the visit as before, and the mother will be +apt to conclude that her doctor, though she has the greatest +confidence in him for the ailments of grown-up persons, is unskilled +in, or at least not interested in, the diseases of little children. +If, on the other hand, the doctor pursues his inquiries into the +management of the child in the home, and if, for example, he finds +that the crying and resistance is not confined to going to stool, but +also takes place when the child is put to bed, and very often at +meal-times as well, then it will be safe for him to conclude that all +the symptoms are due to the same cause--a sort of "negativism" which +is apt to appear in all children who are directed and urged too much, +and whose parents are not careful to hide from them the anxiety and +distress which their conduct occasions. + +If this diagnosis is made, then a full and clear explanation should be +given to the mother, or at any rate to such mothers--and fortunately +they are in the majority--who are capable of appreciating the point of +psychology involved, and of correcting the management of the child so +as to overcome the negativism. To attempt treatment by prescribing +drugs, or in any other way than by correcting the faulty management, +is to court failure. As Charcot has said, in functional disorders it +is not so much the prescription which matters as the prescriber. + +But the task of the doctor is often one of even greater difficulty. +Often enough there will be a combination of organic disturbance with +functional trouble. For example, a girl of eighteen years old suffered +from a pain in the left arm which has persisted on and off since the +olecranon had been fractured when she was two years of age. She was +the youngest of a large family, and had never been separated for a day +from the care and apprehensions of her mother. The joint was stiff, +and there was considerable deformity. The pain always increased when +she was tired or unhappy. Again, a girl had some slight cystitis with +frequent micturition, and this passed by slow degrees into a purely +functional irritability of the bladder, which called for micturition +at frequent intervals both by day and night. In such cases treatment +must endeavour to control both factors--the local organic disturbance +must if possible be removed, and the faults of management corrected. + +It is a good physician who can appreciate and estimate accurately the +temperament of his patient, and the need for this insight is nowhere +greater than in dealing with the disorders of childhood. It can be +acquired only by long practice and familiarity with children. In the +hospital wards we shall learn much that is essential, but we shall not +learn this. The child, who is so sensitive to his environment, shows +but little that is characteristic when admitted to an institution. +Only in the nursery can we learn to estimate the influences which +proceed from parents and nurses of different characters and +temperaments, and the reaction which is produced by them in the child. + +The body of the child is moulded and shaped by the environment in +which it grows. Pure air, a rational diet, free movement, give +strength and symmetry to every part. Faults of hygiene debase the +type, although the type is determined by heredity which in the +individual is beyond our control. Mothers and nurses to-day are well +aware of the need for a rational hygiene. Mother-craft is studied +zealously and with success, and there is no lack of books to give +sound guidance and to show the mean between the dangerous extremes of +coddling and a too Spartan exposure. Yet sometimes it has seemed as if +some mothers whose care for their children's physical health is most +painstaking, who have nothing to learn on the question of diet, of +exercise, of fresh air, or of baths, who measure and weigh and record +with great minuteness, have had their attention so wholly occupied +with the care of the body that they do not appreciate the simultaneous +growth of the mind, or inquire after its welfare. Yet it is the +astounding rapidity with which the mental processes develop that forms +the distinguishing characteristic of the infancy of man. Were it not +for this rapid growth of the cerebral functions, the rearing of +children would be a matter almost as simple and uneventful as the +rearing of live stock. For most animals faults of environment must be +very pronounced to do harm by producing mental unrest and +irritability. Thus, indeed, some wild animal separated from its +fellows and kept in solitary captivity may sicken and waste, though +maintained and fed with every care. Yet if the whole conditions of +life for the animal are not profoundly altered, if the environment is +natural or approximately natural, it is as a rule necessary to care +only for its physical needs, and we need not fear that the results +will be spoiled by the reaction of the mind upon the body. But with +the child it is different; airy nurseries, big gardens, visits to the +seaside, and every advantage that money can buy cannot achieve success +if the child's mind is not at rest, if his sleep is broken, if food is +habitually refused or vomited, or if to leave him alone in the nursery +for a moment is to evoke a fit of passionate crying. + +The grown-up person comes eventually to be able to control this +tremendous organ, this brain, which is the predominant feature of his +race. In the child its functions are always unstable and liable to be +upset. Evidence of mental unrest or fatigue, which is only rarely met +with in grown persons and which then betokens serious disturbance of +the mind, is of comparatively common occurrence in little children. +Habit spasm, bed-wetting, sleep-walking, night terrors, and +convulsions are symptoms which are frequent enough in children, and +there is no need to be unduly alarmed at their occurrence. In adult +age they are found only among persons who must be considered as +neuropathic. To make the point clear, I have chosen examples from the +graver and more serious symptoms of nervous unrest. But it is equally +true that minor symptoms which in adults are universally recognised to +be dependent upon cerebral unrest or fatigue are of everyday +occurrence in childhood. Broken and disturbed sleep, absence of +appetite and persistent refusal of food, gastric pain and discomfort +after meals, nervous vomiting, morbid flushing and blushing, headache, +irritability and excessive emotional display, at whatever age they +occur, are indications of a mind that is not at rest. In children, as +in adults, they may be prominent although the physical surroundings of +the patient may be all that could be desired and all that wealth can +procure. It is an everyday experience that business worries and +responsibilities in men, domestic anxieties or childlessness in women, +have the power to ruin health, even in those who habitually or grossly +break none of its laws. The unstable mind of the child is so sensitive +that cerebral fatigue and irritability are produced by causes which +seem to us extraordinarily trivial. In the little life which the child +leads, a life in which the whole seems to us to be comprised in +dressing and undressing, washing, walking, eating, sleeping, and +playing, it is not easy to detect where the elements of nervous +overstrain lie. Nor is it as a rule in these things that the mischief +is to be found. It is in the personality of mother or nurse, in her +conduct to the child, in her actions and words, in the tone of her +voice when she addresses him, even in the thoughts which pass through +her mind and which show themselves plainly to that marvellously acute +intuition of his, which divines what she has not spoken, that we must +seek for the disturbing element. The mental environment of the child +is created by the mother or the nurse. That is her responsibility and +her opportunity. The conduct of the child must be the criterion of her +success. If things go wrong, if there is constant crying or +ungovernable temper, if sleep and food are persistently refused, or if +there is undue timidity and tearfulness, there is danger that seeds +may be sown from which nervous disorders will spring in the future. + +There are many women who, without any deep thought on the matter, have +the inborn knack of managing children, who seem to understand them, +and have a feeling for them. With them, we say, the children are +always good, and they are good because the element of nervous +overstrain has not arisen. There are other women, often very fond of +children, who are conspicuously lacking in this power. Contact with +one of these well-meaning persons, even for a few days, will +demoralise a whole nursery. Tempers grow wild and unruly, sleep +disappears, fretfulness and irritability take its place. Yet of most +mothers it is probably true that they are neither strikingly +proficient nor utterly deficient in the power of managing children. If +they lack the gift that comes naturally to some women, they learn from +experience and grow instinctively to feel when they have made a false +step with the child. Although by dearly bought experience they learn +wisdom in the management of their children, they nevertheless may not +study the subject with the same care which they devote to matters of +diet and hygiene. It is the mother whose education and understanding +best fits her for this task. In this country a separate nursery and a +separate nursery life for the children is found in nearly all +households among the well-to-do, and the care for the physical needs +of the children is largely taken off the mothers' shoulders by nurses +and nursemaids. That this arrangement is advantageous on the whole +cannot be doubted. In America and on the Continent, where the children +often mingle all day in the general life of the household, and occupy +the ordinary living rooms, experience shows that nerve strain and its +attendant evils are more common than with us. Nevertheless, the +arrangement of a separate nursery has its disadvantages. Nurses are +sometimes not sufficiently educated to have much appreciation of the +mental processes of the child. If the children are restless and +nervous they are content to attribute this to naughtiness or to +constipation, or to some other physical ailment. Their time is usually +so fully occupied that they cannot be expected to be very zealous in +reading books on the management of children. Nevertheless, in +practical matters of detail a good nurse will learn rapidly from a +mother who has given some attention to the subject, and who is able to +give explicit instructions upon definite points. + +It is right that mothers should appreciate the important part which +the environment plays in all the mental processes of children, and in +their physical condition as well; that they should understand that +good temper and happiness mean a proper environment, and that constant +crying and fretfulness, broken sleep, refusal of food, vomiting, undue +thinness, and extreme timidity often indicate that something in this +direction is at fault. + +Nevertheless, we must be careful not to overstate our case. We must +remember how great is the diversity of temperament in children--a +diversity which is produced purely by hereditary factors. The task of +all mothers is by no means of equal difficulty. There are children in +whom quite gross faults in training produce but little permanent +damage; there are others of so sensitive a nervous organisation that +their environment requires the most delicate adjustment, and when +matters have gone wrong, it may be very difficult to restore health of +mind and body. When a peculiarly nervous temperament is inherited, +wisdom in the management of the child is essential, and may sometimes +achieve the happiest results. Heredity is so powerful a factor in the +development of the nervous organisation of the child that, realising +its importance, we should be sparing in our criticism of the results +which the mothers who consult us achieve in the training of their +children. A sensitive, nervous organisation is often the mark of +intellectual possibilities above the average, and the children who are +cast outside the ordinary mould, who are the most wayward, the most +intractable, who react to trifling faults of management with the most +striking symptoms of disturbance, are often those with the greatest +potentialities for achievement and for good. It is natural for the +mother of placid, contented, and perhaps rather unenterprising +children, looking on as a detached outsider, seeing nothing of the +teeming activities of the quick, restless little brain, and the +persistent, though faulty reasoning--it is natural for her to blame +another's work, and to flatter herself that her own routine would have +avoided all these troublesome complications. The mother of the nervous +child may often rightly take comfort in the thought that her child is +worth the extra trouble and the extra care which he demands, because +he is sent into the world with mechanism which, just because it is +more powerful than the common run, is more difficult to master and +takes longer to control and to apply for useful ends. + +It is through the mother, and by means of her alone, that the doctor +can influence the conduct of the child. Without her co-operation, or +if she fails to appreciate the whole situation, with the best will in +the world, we are powerless to help. Fortunately with the majority of +educated mothers there is no difficulty. Their powers of observation +in all matters concerning their children are usually very great. It is +their interpretation of what they have observed that is often faulty. +Thus, in the example given above, the mother observes correctly that +defæcation is inhibited, and produces crying and resistance. It is +her interpretation that the cause is to be found in pain that is at +fault. Again, a mother may bring her infant for tongue-tie. She has +observed correctly that the child is unable to sustain the suction +necessary for efficient lactation, and has hit upon this fanciful and +traditional explanation. The doctor, who knows that the tongue takes +no part in the act of sucking, will probably be able to demonstrate +that the failure to suck is due to nasal obstruction, and that the +child is forced to let go the nipple because respiration is impeded. +The opportunities for close observation of the child which mothers +enjoy are so great that we shall not often be justified in +disregarding their statements. But if we are able to give the true +explanation of the symptoms, it will seldom happen that the mother +will fail to be convinced, because the explanation, if true, will fit +accurately with all that has been observed. Thus the mother of the +child in whom defæcation is inhibited by negativism may have made +further observations. For example, she may have noted that the +so-called constipation causes fretfulness, that it is almost always +benefited by a visit to the country or seaside, or that it has become +much worse since a new nurse, who is much distressed by it, has taken +over the management of the child. To this mother the explanation must +be extended to fit these observations, of the accuracy of which there +need be no doubt. Fretfulness and negativism with all children whose +management is at fault come in waves and cycles. The child, naughty +and almost unmanageable one week, may behave as a model of propriety +the next. The negativism and refusal to go to stool are the outcome of +the nervous unrest, not its cause. Again, the nervous child, like the +adult neuropath, very often improves for the time being with every +change of scene and surroundings. It is the _ennui_ and monotony of +daily existence, in contact with the same restricted circle, that +becomes insupportable and brings into prominence the lack of moral +discipline, the fretfulness, and spirit of opposition. Lastly, the +conduct of the nervous child is determined to a great extent by +suggestions derived from the grown-up people around him. Refusal of +food, refusal of sleep, refusal to go to stool, as we shall see later, +only become frequent or habitual when the child's conduct visibly +distresses the nurse or mother, and when the child fully appreciates +the stir which he is creating. The mother will readily understand that +in such a case, where constipation varies in degree according as +different persons take charge of the child, the explanation offered is +that which alone fits with the observed facts. A full and free +discussion between mother and doctor, repeated it may be more than +once, may be necessary before the truth is arrived at, and a line of +action decided upon. Only so can the doctor, remote as he is from the +environment of the child, intervene to mould its nature and shape its +conduct. + +If the doctor is to fit himself to give advice of this sort, he must +be a close observer of little children. He must not consider it +beneath his dignity to study nursery life and nursery ways. There he +will find the very beginnings of things, the growing point, as it +were, of all neuropathy. A man of fifty, who in many other ways showed +evidence of a highly nervous temperament, had especially one +well-marked phobia, the fear of falling downstairs. It had never been +absent all his life, and he had grown used to making the descent of +the stairs clinging firmly to the stair-rail. Family tradition +assigned this infirmity to a fall downstairs in early childhood. But +all children fall downstairs and are none the worse. The persistence +of the fear was due, I make no doubt, to the attitude of the parents +or nurse, who made much of the accident, impressed the occasion +strongly on the child's memory, and surrounded him thereafter with +precautions which sapped his confidence and fanned his fears. + +In what follows we will consider first the subject of nursery +management, searching in it for the origin of the common disorders of +conduct both of childhood and of later life. I have grouped these +nursery observations under the heads of four characteristic features +of the child's psychology--his Imitativeness, his Suggestibility, his +Love of Power, and his acute though limited Reasoning Faculties. I +feel that some such brief examination is necessary if we are to +understand correctly the ætiology of some of the most troublesome +disorders of childhood, such as enuresis, anorexia, dyspepsia, or +constipation, disorders in which the nervous element is perhaps to-day +not sufficiently emphasised. Finally, we can evolve a kind of nursery +psycho-therapeutics--a subject which is not only of fascinating +interest in itself, but which repays consideration by the success +which it brings to our efforts to cure and control. + + + + +CHAPTER II + +OBSERVATIONS IN THE NURSERY + + +_(a)_ THE IMITATIVENESS OF THE CHILD + +It is in the second and third years of the child's life that the +rapidity of the development of the mental processes is most apparent, +and it is with that age that we may begin a closer examination. At +first sight it might seem more reasonable to adopt a strictly +chronological order, and to start with the infant from the day of his +birth. Since, however, we can only interpret the mind of the child by +our knowledge of our own mental processes, the study of the older +child and of the later stages is in reality the simpler task. The +younger the infant, the greater the difficulties become, so that our +task is not so much to trace the development of a process from simple +and early forms to those which are later and more complex, as to +follow a track which is comparatively plain in later childhood, but +grows faint as the beginnings of life are approached. + +At the age, then, of two or three the first quality of the child which +may arrest our attention is his extreme imitativeness. Not that the +imitation on his part is in any way conscious; but like a mirror he +reflects in every action and in every word all that he sees and hears +going on around him. We must recognise that in these early days his +words and actions are not an independent growth, with roots in his own +consciousness, but are often only the reflection of the words and +actions of others. How completely speech is imitative is shown by the +readiness with which a child contracts the local accent of his +birthplace. The London parents awake with horror to find their baby an +indubitable Cockney; the speech of the child bred beyond the Tweed +proclaims him a veritable Scot. Again, some people are apt to adopt a +somewhat peremptory tone in addressing little children. Often they do +not trouble to give to their voices that polite or deferential +inflection which they habitually use when speaking to older people. +Listen to a party of nurses in the Park addressing their charges. As +if they knew that their commands have small chance of being obeyed, +they shout them with incisive force. "Come along at once when I tell +you," they say. And the child faithfully reflects it all back, and is +heard ordering his little sister about like a drill sergeant, or +curtly bidding his grandmother change her seat to suit his pleasure. +If we are to have pretty phrases and tones of voice, mothers must see +to it that the child habitually hears no other. Again, mothers will +complain that their child is deaf, or, at any rate, that he has the +bad habit of responding to all remarks addressed to him by saying, +"What?" or, worse still, "Eh?" Often enough the reason that he does so +is not that the child is deaf, nor that he is particularly slow to +understand, but simply that he himself speaks so indistinctly that no +matter what he says to the grown-up people around him, they bend over +him and themselves utter the objectionable word. + +We all hate the tell-tale child, and when a boy comes in from his walk +and has much to say of the wicked behaviour of his little sister on +the afternoon's outing, his mother is apt to see in this a most horrid +tendency towards tale-bearing and currying of favour. She does not +realise that day by day, when the children have come in from their +walk, she has asked nurse in their hearing if they have been good +children; and when, as often happens, they have not, the nurse has +duly recounted their shortcomings, with the laudable notion of putting +them to shame, and of emphasising to them the wickedness of their +backsliding--and this son of hers is no hypocrite, but speaks only, as +all children speak, in faithful reproduction of all that he hears. +Those grown-up persons who are in charge of the children must realise +that the child's vocabulary is their vocabulary, not his own. It is +unfortunate, but I think not unavoidable, that so often almost the +earliest words that the infant learns to speak are words of reproof, +or chiding, or repression. The baby scolds himself with gusto, +uttering reproof in the very tone of his elders: "No, no," "Naughty," +or "Dirty," or "Baby shocked." + +Speech, then, is imitative from the first, if we except the early baby +sounds with reduplication of consonants to which in course of time +definite meaning becomes attached, as "Ba-ba," "Ma-ma," "Na-na," +"Ta-ta," and so forth. Action only becomes imitative at a somewhat +later stage. The first purposive movements of the child's limbs are +carried out in order to evoke tactile sensations. He delights to +stimulate and develop the sense of touch. At first he has no knowledge +of distance, and his reach exceeds his grasp. He will strain to touch +and hold distant objects. Gradually he learns the limitations of +space, and will pick up and hold an object in his hand with precision. +Often he conveys everything to his mouth, not because his teeth are +worrying him, or because he is hungry, as we hear sometimes alleged, +but because his mouth, lips, and tongue are more sensitive, because +more plentifully furnished with the nerves of tactile sensation. By +constant practice the sense of touch and the precision of the movement +of his hands are slowly developed, and not these alone, for the child +in acquiring these powers has developed also the centres in the brain +which control the voluntary movements. When the child can walk he +continues these grasping and touching exercises in a wider sphere. As +the child of fifteen or eighteen months moves about the room, no +object within his reach is passed by. He stretches out his hand to +touch and seize upon everything, and to experience the joy of +imparting motion to it. The impulse to develop tactile sensation and +precision in the movements of his hands compels him with irresistible +force. It is foolish to attempt to repress it. It is foolish, because +it is a necessary phase in his development, and moreover a passing +phase. No doubt it is annoying to his elders while it lasts, but the +only wise course is to try to thwart as little as we can his +legitimate desire to hold and grasp the objects, and even to assist +him in every way possible. But the mother must assist him only by +allowing free play to his attempts. To hand him the object is to +deprive the exercise of most of its value. Incidentally she may teach +him the virtue of putting things back in their proper places, an +accomplishment in which he will soon grow to take a proper pride. If +she attempts continually to turn him from his purpose, reproving him +and snatching things from him, she prolongs the grasping phase beyond +its usual limits. And she does a worse thing at the same time. Lest +the quicker hands of his nurse should intervene to snatch the prize +away before he has grasped it, he too learns to snatch, with a sudden +clumsy movement that overturns, or breaks, or spills. If left to +himself he will soon acquire the dexterity he desires. He may overturn +objects at first, or let them fall, but this he regards as failure, +which he soon overcomes. A child of twenty months, whose development +in this particular way has not been impeded by unwise repression, will +pick out the object on which he has set his heart, play with it, +finger it, and replace it, and he will do it deliberately and +carefully, with a clear desire to avoid mishap. Dr. Montessori, who +has developed into a system the art of teaching young children to +learn precision of movement and to develop the nerve centres which +control movement, tells in her book a story which well illustrates +this point.[1] + +[Footnote 1: _The Montessori Method_, pp. 84, 85.] + +"The directress of the Casa del Bambini at Milan constructed under one +of the windows a long, narrow shelf, upon which she placed the little +tables containing the metal geometric forms used in the first lesson +in design. But the shelf was too narrow, and it often happened that +the children in selecting the pieces which they wished to use would +allow one of the little tables to fall to the floor, thus upsetting +with great noise all the metal pieces which it held. The directress +intended to have the shelf changed, but the carpenter was slow in +coming, and while waiting for him she discovered that the children had +learned to handle these materials so carefully that in spite of the +narrow and sloping shelf, the little tables no longer fell to the +ground. The children, by carefully directing their movements, had +overcome the defect in this piece of furniture." + +By slow degrees the child learns to command his movements. If his +efforts are aided and not thwarted, before he is two years old he will +have become capable of conducting himself correctly, yet with perfect +freedom. The worst result of the continual repression which may be +constantly practised in the mistaken belief that the grasping phase is +a bad habit which persistent opposition will eradicate, is the nervous +unrest and irritation which it produces in the child. A passionate fit +of crying is too often the result of the thwarting of his nature, and +the same process repeated over and over again, day by day, almost hour +by hour, is apt to leave its mark in unsatisfied longing, +irritability, and unrest. Above all, the child requires liberty of +action. + +We have here an admirable example of the effect of environment in +developing the child's powers. A caged animal is a creature deprived +of the stimulus of environment, and bereft therefore to a great extent +of the skill which we call instinct, by which it procures its food, +guarantees its safety from attack, constructs its home, cares for its +young, and procreates its species. If, metaphorically speaking, we +encircle the child with a cage, if we constantly intervene to +interpose something between him and the stimulus of his environment, +his characteristic powers are kept in abeyance or retarded, just as +the marvellous instinct of the wild animals becomes less efficient in +captivity. + +The grasping phase is but a preliminary to more complex activities. +Just as in schooldays we were taught with much labour to make +pot-hooks and hangers efficiently before we were promoted to real +attempts at writing, so before the child can really perform tasks with +a definite meaning and purpose, he must learn to control the finer +movements of his hands. Once the grasping phase, the stage of +pot-hooks, is successfully past--and the end of the second year in a +well-managed child should see its close--the child sets himself with +enthusiasm to wider tasks. To him washing and dressing, fetching his +shoes and buttoning his gaiters, all the processes of his simple +little life, should be matters of the most enthralling interest, in +which he is eager to take his part and increasingly capable of doing +so. In the Montessori system there is provided an elaborate apparatus, +the didactic material, designed to cultivate tactile sensation and the +perception of sense stimuli. It will generally suffice to advise the +mother to make use of the ordinary apparatus of the nursery. The +imitativeness of the young child is so great that he will repeat in +almost every detail all the actions of his nurse as she carries out +the daily routine. At eighteen months of age, when the electric light +is turned on in his nursery, the child will at once go to the curtains +and make attempts to draw them. At the same age a little girl will +weigh her doll in her own weighing-machine, will take every precaution +that the nurse takes in her own case, and will even stoop down +anxiously to peer at the dial, just as she has seen her mother and +nurse do on the weekly weighing night. But at a very early age +children appreciate the difference between the real and the +make-believe. They desire above all things to do acts of real service. +At the age of two a child should know where every article for the +nursery table is kept. He will fetch the tablecloth and help to put it +in place, spoons and cups and saucers will be carried carefully to the +table, and when the meal is over he will want to help to clear it all +away. All this is to him a great delight, and the good nurse will +encourage it in the children, because she sees that in doing so they +gain quickness and dexterity and poise of body. The first purposive +movements of the child should be welcomed and encouraged. It is +foolish and wrong to repress them, as many nurses do, because the +child in his attempts gets in the way, and no doubt for a time delays +rather than expedites preparations. The child who is made to sit +immobile in his chair while everything is done for him is losing +precious hours of learning and of practice. It is useless, and to my +mind a little distasteful, to substitute for all this wonderful child +activity the artificial symbolism of the kindergarten school in which +children are taught to sing songs or go through certain semi-dramatic +activities which savour too much of a performance acquired by precise +instruction. If such accomplishments are desired, they may be added +to, but they must not replace, the more workaday activities of the +little child. The child whose impulses towards purposive action are +encouraged is generally a happy child, with a mind at rest. When those +impulses are restrained, mental unrest and irritability are apt to +appear, and toys and picture books and kindergarten games will not be +sufficient to restore his natural peace of mind. + + +_(b)_ THE SUGGESTIBILITY OF THE CHILD + +We may pass from considering the imitativeness of the child to study a +second and closely related quality, his suggestibility. His conception +of himself as a separate individual, of his ego, only gradually +emerges. It is profoundly modified by ideas derived from those around +him. Because of his lack of acquired experience, there is in the child +an extreme sensitiveness to impressions from outside. Take, for +example, a matter that is sometimes one of great difficulty, the +child's likes and dislikes for food. Many mothers make complaint that +there are innumerable articles of diet which the child will not take: +that he will not drink milk, or that he will not eat fat, or meat, or +vegetables, or milk puddings. There are people who believe that these +peculiarities of taste correspond with idiosyncrasies of digestion, +and that children instinctively turn from what would do them harm. I +do not believe that there is much truth in this contention. If we +watch an infant after weaning, at the time when his diet is gradually +being enlarged to include more solid food, with new and varied +flavours, we may see his attention arrested by the strange sensations. +With solid or crisp food there may be a good deal of hesitation and +fumbling before he sets himself to masticate and swallow. With the +unaccustomed flavour of gravy or fruit juice there may be seen on his +face a look of hesitation or surprise. In the stolid and placid child +these manifestations are as a rule but little marked, and pleasurable +sensations clearly predominate. With children of more nervous +temperament it is clear that sensations of taste are much more acute. +Even in earliest infancy, children have a way of proclaiming their +nervous inheritance by the repugnance which they show to even trifling +changes in the taste or composition of their food. We see the same +sensitiveness in their behaviour to medicines. The mixture which one +child will swallow without resentment, and almost eagerly, provokes +every expression of disgust from another, or is even vomited at once. +In piloting the child through this phase, during which he starts +nervously at all unaccustomed sensations and flavours, the attitude of +mother and nurse is of supreme importance. It is unwise to attempt +force; it is equally unwise, by excessive coaxing, cajoling, and +entreaty, to concentrate the child's attention on the matter. If +either is tried every meal is apt to become a signal for struggling +and tears. The phase, whether it is short or long continued, must be +accepted as in the natural order of things, and patience will see its +end. The management of this symptom,--refusal of food and an +apparently complete absence of desire for food,--which is almost the +commonest neurosis of childhood, will be dealt with later. Here it is +mentioned because I wish to emphasise that if too much is made of a +passing hesitation over any one article of food, if it becomes the +belief of the mother or nurse that a strong distaste is present, then +if she is not careful her attitude in offering it, because she is +apprehensive of refusal, will exert a powerful suggestion on the +child's mind. Still worse, it may cause words to be used in the +child's hearing referring to this peculiarity of his. By frequent +repetition it becomes fixed in his mind that this is part of his own +individuality. He sees himself--and takes great pleasure in the +thought--as a strange child, who by these peculiarities creates +considerable interest in the minds of the grown-up people around him. +When the suggestion takes root it becomes fixed, and as likely as not +it will persist for his lifetime. It may be habitually said of a child +that, unlike his brothers and sisters, he will never eat bananas, and +thereafter till the day of his death he may feel it almost a physical +impossibility to gulp down a morsel of the offending fruit. So, too, +there are people who can bolt their food with the best of us, who yet +declare themselves incapable of swallowing a pill. + +Another example of the force of suggestion, whether unconscious or +openly exercised by speech, is given us in the matter of sleep. Among +adults the act of going to bed serves as a powerful suggestion to +induce sleep. Seldom do we seek rest so tired physically that we drop +off to sleep from the irresistible force of sheer exhaustion. Yet as +soon as the healthy man whose mind is at peace, whose nerves are not +on edge, finds himself in bed, his eyes close almost with the force of +a hypnotic suggestion, and he drops off to sleep. With some of us the +suggestion is only powerful in our own bed, that on which it has acted +on unnumbered nights. We cannot, as we say, sleep in a strange bed. It +is suggestion, not direct will power, that acts. No one can absolutely +will himself to sleep. In insomnia it is the attempt to replace the +unconscious auto-suggestion by a conscious voluntary effort of will +that causes the difficulty. A thousand times in the night we resolve +that now we _will_ sleep. If we could but cease to make these +fruitless efforts, sleep might come of itself and the suggestion or +habit be re-established. + +In little children the suggestion of sleep, provoked by being placed +in bed, sometimes acts very irregularly. Often it may succeed for a +week or two, and then some untoward happening breaks the habit, and +night after night, for a long time, sleep is refused. The wakeful +child put to bed, resents the process, and cries and sobs miserably, +to the infinite distress of his mother. It then becomes just as likely +that the child will connect his bed in his mind, not with rest and +sleep, but with sobbing and crying on his part, and mingled entreaties +and scoldings from his nurse or mother. An important part in this +perversion of the suggestion is played by the attitude of the person +who puts the child to bed. Often the nurse is uniformly successful, +while the mother, who is perhaps more distressed by the sobbing of the +child, as consistently fails, because she has been unable to hide her +apprehension from him, and has conveyed to his mind a sense of his own +power. + +Just in the same way, grown-up people, filled with anxiety because of +the helplessness of the young child, unable to divest their minds of +the fears of the hundred and one accidents that may befall, or that +within their own experience have befallen, a little child at one time +or another, unconsciously make unwise suggestions which fill his mind +with apprehension and terror. They do not like their children to show +fear of animals. Nor would they if it were not that their own +apprehension that the child may be hurt communicates itself to him. +The child is not of himself afraid to fall, it is they who suffer the +anxiety and show it by treating the fall as a disaster. The child is +not of himself afraid to be left alone in a room. It is they who sap +his confidence in himself, because they do not venture to leave him +out of their sight, from a nameless dread of what may happen. A little +girl cut her finger and ran to her nurse, pleased and interested: +"See," she said, seeing it bleed, "fingers all jammy." Only when the +nurse grasped her with unwise expressions of horror did she break into +cries of fear. A town-bred nurse, who is afraid of cows, will make +every country walk an ordeal of fear for the children. + +Every mother must be made to realise the ease with which these +unconscious suggestions act upon the mind of the little child, and +should school herself to be strong to make her child strong, and to +see to it that all this suggestive force is utilised for good and not +for evil. + +It is upon this susceptibility to suggestion that a great part of his +early education reposes. No one who is incapable of profiting by this +natural disposition of the child can be successful in her management +of him. Turn where you will in his daily life the influence of this +force of suggestion is clearly apparent. The child does without +questioning that which he is confidently expected to do. Thus he will +eat what is given him, and sleep soundly when he is put to bed if only +the appropriate suggestion and not the contrary is made to him. Again +we have seen that a perversion of suggestion of this sort is a common +source of constipation in early childhood. If the child's attention is +directed towards the difficulty, if he is urged or ordered or appealed +to to perform his part, if failure is looked upon as a serious +misfortune, the bowels may remain obstinately unmoved. In children as +in adults a too great concentration of attention inhibits the action +of the bowels, and constipation, in many persons, is due to the +attempt to substitute will power for the force of habitual suggestion. +No matter what other treatment we adopt, the mother must be careful to +hide from the child that his failure is distressing to her. A cheerful +optimism which teaches him to regard himself as one who is +conspicuously regular in his habits, and who has a reputation in this +respect to live up to is sure to succeed. To talk before him of his +habitual constipation, and to worry over the difficulty, is as surely +to fail. In the same way unwise suggestion can interfere with the +passing of water at regular and suitable intervals. There are children +who constantly desire to pass water on any occasion, which is +conspicuously inappropriate, because their attention has been +concentrated on the sensations in the bladder. Often enough when at +great inconvenience opportunity has been found, the desire has passed +away, and all the trouble has proved needless. It is not too much to +say that every occupation and every action of the day can be made +delightful or hateful to the child, according to the suggestion with +which it is presented and introduced. Dressing and undressing, eating +and drinking, bathing, washing, the putting away of toys, even going +to bed, can be made matters of enthralling interest or delight, or a +subject for tears and opposition, according to the bias which is given +to the child's mind by the words, attitude, and actions of nurses and +mothers. + +Here we approach very near to the heart of the subject. Stripped of +all that is not essential we see the problem of the management of +children reduced to the interplay between the adult mind and the mind +of the receptive suggestible child. That which is thought of and +feared for the child, that he rapidly becomes. Placid, comfortable +people who do not worry about their children find their children +sensible and easy to manage. Parents who take a pride in the daring +and naughty pranks of their children unconsciously convey the +suggestion to their minds that such conduct is characteristic of them. +Nervous and apprehensive parents who are distressed when the child +refuses to eat or to sleep, and who worry all day long over possible +sources of danger to him, are forced to watch their child acquire a +reputation for nervousness, which, as always, is passively accepted +and consistently acted up to. Differences in type, determined by +hereditary factors, no doubt, exist and are often strongly marked. Yet +it is not untrue to say that variations in children, dependent upon +heredity, show chiefly in the relative susceptibility or +insusceptibility of the child to the influences of environment and +management. It is no easy task to distinguish between the nervous +child and the child of the nervous mother, between the child who +inherits an unusually sensitive nervous system and the child who is +nervous only because he breathes constantly an atmosphere charged with +doubt and anxiety. + + +(_c_) THE CHILD'S LOVE OF POWER + +Let us study briefly a third quality of the child which, for want of a +better name, I have called after the ruling passion of mankind, his +love of power. Perhaps it would be better to call it his love of being +in the centre of the picture. It is his constant desire to make his +environment revolve around him and to attract all attention to +himself. Somewhat later in life this desire to attract attention, at +all costs, is well seen in the type of girl popularly regarded as +hysterical. The impulse is then a morbid and debased impulse; in the +child it is natural and, within limits, praiseworthy. A girl of this +sort, who feels that she is not likely to attract attention because of +any special gifts of beauty or intellect which she may possess, +becomes conscious that she can always arouse interest by the severity +of her bodily sufferings. The suggestion acts upon her unstable mind, +and forthwith she becomes paralysed, or a cripple, or dumb, presenting +a mimicry or travesty of some bodily ailment with which she is more or +less familiar. "Hysterical" girls will even apply caustic to the skin +in order to produce some strange eruption which, while it sorely +puzzles us doctors, will excite widespread interest and commiseration. +Now little children will seldom carry their desire to attract +attention so far as to work upon the feelings of their parents by +simulating disease. They have not the necessary knowledge to play the +part, and even if they make the attempt, complaining of this or that +symptom which they notice has aroused the interest of their elders, +the simulation is not likely to be so successful as to deceive even a +superficial observer. But within the limits of their own powers, +children are past masters in attracting attention. The little child is +unable to take part in any sustained conversation; most of his +talking, indeed, is done when he is alone, and is addressed to no one +in particular. But he knows well that by a given action he can produce +a given reaction in his mother and nurse. A great part of what is said +to him--too great a part by far--comes under the category of reproof +or repression. He is forbidden to do this or that, coaxed, cajoled, +threatened long before he is old enough to understand the meaning of +the words spoken, although he knows the tone in which they are uttered +and loves to produce it at will. How he enjoys it all! Watch him draw +near the fire, the one place that is forbidden him. He does not mean +to do himself harm. He knows that it is hot and would hurt him, but +for the time being he is out of the picture and he is intent on +producing the expected response, the reproof tone from his mother +which he knows so well. He approaches it warily, often anticipating +his mother's part and vigorously scolding himself. He desires nothing +more than that his mother should repeat the reproof, forbidding him a +dozen times. The mind of all little children tends easily to work in a +groove. It delights in repetition and it evoking not the unexpected +but the expected. If his sport is stopped by his mother losing +patience and removing him bodily from the danger zone, his sense of +impotence finds vent in passionate crying. But if his mother takes no +notice, the sport soon loses its savour. He is conscious that somehow +or other it has fallen flat, and he flits off to other employment. + +Mothers will complain that children seem to take a perverse pleasure +in evoking reproof, appeals, entreaties, and exhortations. A small boy +of four who had several times repeated the particular sin to which his +attention had been directed by the frequency of his mother's warnings +and entreaties, finding that on this occasion she had decided to take +no notice, approached her with a troubled face: "Are you not angry?" +he said; "are you not disappointed?" In reality the naughty child is +often only the child who has become master of his mother's or his +nurse's responses, and can produce at will the effect he desires. The +idea that the child possesses a strong will, which can and must be +broken by persistent opposition, is based upon this tendency of the +child. It is an entire misconception of the situation: Strength of +will and fixity of purpose are among the last powers which the human +mind develops. In little children they are conspicuously absent. What +appears to us as a fixed and persistent desire to perform a definite +action in spite of all we can say or do, is often no more than the +desire to produce the familiar tones of reproof, to traverse again the +familiar ground, to attract attention and to find himself again the +centre of the picture. If no one pays any attention and no one +reproves, he soon gives up the attempt. If too much is made of any one +action of the child, a strong impression is made on his mind and he +cannot choose but return to it again and again. + +This little drama of the fireplace may teach us a great deal in the +management of children. The wise mother and nurse will find a hundred +devices to catch the child's attention and lure him away from the +danger zone without the incident making any impression on his mind at +all, and will not call attention to it by repeated reproofs or +warnings which will certainly lead him straight back to the spot. + +In matters of greater moment the same impulse to oppose the will of +those around him is seen. In considering the point of the child's +susceptibility to suggestion, we have mentioned the refusal of sleep +and the refusal of food. In both it is possible to detect the +influence of this pronounced force of opposition. As the child lies +sobbing or screaming in bed, every new approach to him, every fresh +attempt at pacification, renews the force of his opposition in a +crescendo of sound. But it is in his refusal of food that the child is +apt to find his chief opportunity. Meal-times degenerate into a +struggle. There at least he can show his complete mastery of the +situation. No one can swallow his food for him, and he knows it. He +can clench his teeth and shake his head and obstinately refuse every +morsel offered. He can hold food in his mouth for half an hour at a +time and remain deaf to all the appeals of his helpless nurse. If she +tries force, he quells the attempt by a storm of crying. If she +declines upon entreaty and coaxing, he will not be persuaded. It is +the little scene of the fireplace over again. The attempts at force or +the attempts at persuasion, by making much of it, have concentrated +the attention of the child upon the difficulty, and have taught him +his own power to dominate the situation. + +It is right that parents should realise that the disturbing and +irritating element in the child's environment is nearly always +provided by the intrusion of the adult mind and its contact with the +child's. Some supervision and some intrusion, therefore, is of course +absolutely necessary, but the best-regulated nursery is that in which +it is least evident. Something is definitely wrong if a child of two +years will not play for half an hour at a time happily and busily in a +room by himself. It is an even better test if the child will play +amicably by himself with nurse or mother in the room, without the two +parties crossing swords on a single occasion, without reproof or +repression on the one side or undue attempts to attract attention on +the other. If the child is entirely dependent upon the participation +of grown-up persons in his pursuits, then not only do those pursuits +lose much of their educative force, but they become a positive source +of danger because of the constant interplay of personality with +personality. The child who, seated on the ground, will play with his +toys by himself, rises with a brain that is stimulated but not +exhausted. Only very rarely do we find that solitary play, or play +between children, is too exciting. In older children of very quick +intelligence and nervous temperament we occasionally find that the +pace which they themselves set is too exciting or exhausting. I recall +a little boy of seven, an only child of particularly wise and +thoughtful parents, who was brought to me with the complaint that he +exhausted himself utterly both in body and mind by the intense nervous +energy which he threw into his pursuits. For instance, he had been +interested in the maps illustrating the various fronts in the European +War, with which the walls of his father's study were hung, and +although left entirely by himself he had become intensely excited and +exhausted by the eagerness with which he had spent a whole morning, +with a wealth of imaginative force, in drawing a map of the garden of +his house and converting it into the likeness of a war map, filled +with imaginary Army Corps. Such excessive expenditure of nervous force +is unusual even in older children, and as in this case is found +usually only when there is a pronounced nervous inheritance. In little +children in the nursery, solitary play or play between themselves +seldom produces nervous exhaustion. It is quite otherwise when the +child is dependent to a too great extent upon the participation of +adults. It is almost impossible for the mother and nurse not to take +the leading part in the exchange of ideas, and no matter what may be +their good intentions, the pace set is apt to be too great. +Environment, without the intrusion of the adult mind, is best able to +adjust the necessary stimulus and produce development without +exhaustion. Play with grown-up persons, the reading aloud of story +books, the showing of pictures, and so forth, undoubtedly have their +own importance, but they should be confined within strict limits and +to a definite hour in the daily routine. There is sometimes too great +a tendency for parents to make playthings of their little children. +Save at stated times, they must curb their desire to join in their +games, to gather them in their arms, to hold them on their knee, while +they stimulate their minds by a constant succession of new +impressions. With an only child, whose existence is the single +preoccupation of the nurse and mother, and, often enough, of the +father as well, it is difficult to avoid this fault. Yet, if wisdom is +not learnt, the damage to the child may be distressingly serious. He +rapidly grows incapable of supporting life without this excessive +stimulation. Without the constant society and attention of a grown +person, he feels himself lost. He cannot be left alone, and yet cannot +enjoy the society he craves. He grows more and more restless, +dominating the whole situation more and more, constantly plucking at +his nurse's skirts, perversely refusing every new sensation that is +offered him to still his restlessness for a moment. The result of all +this stimulation is mental irritability and exhaustion, which in turn +is often the direct cause of refusal of food, dyspepsia, wakefulness, +and excessive crying. + +The devices by which children will attract to themselves the +attention of their elders, and which, if successful, are repeated with +an almost insane persistence, take on the most varied forms. Sometimes +the child persistently makes use of an expression, or asks questions, +which produce a pleasant stir of shocked surprise and renewed reproofs +and expostulations. One little boy shouted the word "stomachs" with +unwearied persistence for many weeks together. A little girl dismayed +her parents and continued in spite of all they could do to prevent her +to ask every one if they were about to pass water. + +Disorders of conduct of this sort are not really difficult to control. +Suitable punishment will succeed, provided also that the child is +deprived of the sense of satisfaction which he has in the interest +which his conduct excites. His behaviour is only of importance because +it indicates certain faults in his environment and a certain element +of nervous unrest and overstrain. + +The young child demands from his environment that it should give him +two things--security and liberty. He must have security from shocks to +his nervous system. It is true that from the greater shocks the +children of the well-to-do are as a rule carefully guarded. No one +threatens or ill-uses them. They are not terrified by drunken brawls +or scenes of passion. They are not made fearful by the superstitions +of ignorant people. Nevertheless, by the summation of stimuli little +emotions constantly repeated can have effects no less grave upon +their nervous system. From this constantly acting irritation the child +needs security. In the second place, he requires liberty to develop +his own initiative, which should be stimulated and sustained and +directed. Without liberty and without security conduct cannot fail to +become abnormal. + + +(_d_) THE REASONING POWER OF THE CHILD + +Before we proceed to a closer examination of the various symptoms of +nervous unrest in detail, we may very briefly consider the scope and +power of the child's understanding. As a rule I am sure that it is +grossly underestimated. The mental processes of the child are far +ahead of his power of speech. The capacity for understanding speech is +well advanced, and an appeal to reason is often successful while the +child is still powerless to express his own thoughts in words. Because +he cannot so express himself there is a tendency to underestimate the +acuteness of his reasoning, to talk down to him, and to imagine that +he can be imposed upon by any fiction which seems likely to suit the +purpose of the moment. A child of eighteen months is not too young to +be talked to in a quiet, straightforward, sensible way. Only if he is +treated as a reasonable being can we expect his reasoning faculties to +develop. Children dislike intensely the unexplained intervention of +force. If a pair of scissors, left by an oversight lying about, has +been grasped, the first impulse of the mother is to snatch the danger +hurriedly from the child's hands, and her action will generally be +followed by resistance and a storm of weeping. She will do better to +approach him quietly, telling him that scissors hurt babies, and show +him where to place them out of harm's way. Watch a child at play after +his midday meal. He has been out in his perambulator half the morning, +and for the other half has been deep in his midday sleep. Now that +dinner is over he is for a moment master of his time and busily +engaged in some pursuit dear to his heart. At two o'clock inexorable +routine ordains that he must again be placed in the perambulator and +wheeled forth on a fresh expedition. If the nurse does not know her +business she will swoop down upon him, place him on her knee, and +begin to envelop his struggling little body in his outdoor clothes, +scolding his naughtiness as he kicks and screams. If she has a way +with children she will open the cupboard door and call on him to help +find his gaiters and his shoes because it is time for his walk. In a +moment he will leave his toys, forgetting all about them in the joy of +this new activity. + +If the reason for things is explained to children they grow quick to +understand quite complicated explanations. A little girl, not yet two, +was playing with her Noah's Ark on the dining-room table with its +polished surface. The mother interposed a cloth, explaining that the +animals would scratch the table if the cloth were not there. Within a +few minutes the child twice lifted the cloth, peering under it and +saying, "Not scratch table." Yet how often do we find +facetiously-minded persons confound their reasoning and confuse their +judgment by foolish speeches and cock-and-bull tales, which, just +because of their foolishness, seem to them well adapted to the infant +intelligence. + +An attempt to deceive the child is almost always wrong, and because of +our tendency to underestimate the child's intelligence it generally +fails. If a little girl has a sore throat, and the doctor comes to see +her, she knows quite well that she is the prospective patient. It is +useless for the mother to begin proceedings by trying to convince her +that this is not so--that mother has a sore throat too. Such a plan +only arouses apprehension, because the child scents danger in the +artifice. + +Closely connected with the reasoning powers of the child is the +difficult question of the growth of his appreciation of right and +wrong, or, to put it in another way, the growth of obedience or +disobedience. Sooner or later the child must learn to obey; on that +there can be no two opinions. Nevertheless, I think there can be no +doubt that far more harm is done by an over-emphasis of authority than +by its neglect. If the nurse or mother is of strong character, and the +authority is exercised persistently and remorselessly, so that the +whole life of the child is dominated, much as the recruit's existence +in the barrack yard is dominated by the drill sergeant, his +independence of nature is crushed. He is certain to become a +colourless and uninteresting child; he runs a grave risk of growing +sly, broken-spirited, and a currier of favour. If a child is +ruthlessly punished for disobedience from his earliest years, there +is, it need hardly be said, a grave risk that he will learn to lie to +save his skin. I have seen a few such cases of what I may call the +remorseless exercise of authority, and the result has not been +pleasing. Fortunately, perhaps, not many women have the heart to adopt +this attitude to the waywardness of little children--a waywardness to +which their whole nature compels them by their pressing need to +cultivate tactile sensations, to experiment, and to explore. +Therefore, much more commonly, the authority is exercised +intermittently and capriciously, with the result that the child's +judgment is clouded and confused. Conduct which is received +indulgently or even encouraged at one moment is sternly reprimanded at +another. Every one who has the management of little children must +above all see to it, whatever the degree of stringency in discipline +which they decide to adopt, that their attitude is always consistent. +The less that is forbidden the better, but when the line is drawn it +must be adhered to. If once the child learns that the force which +restrains him can be made to yield to his own efforts, the future is +black indeed. From that day he sets himself to strike down authority +with a success which encourages him to further efforts. I have known a +child of five years terrorise his mother and get his own way by the +threat, "I will go into one of my furies." + +The difficulty of successfully enforcing authority, and of carrying +off the victory if that authority is disputed, should make mothers +wary of drawing too tight a rein. The conflict between parent and +child must always be distressing and must always be prejudicial to the +child, whatever its outcome, whether it brings to him victory or +defeat. He learns from it either an undue sense of power or an undue +sense of helplessness, and the knowledge of neither is to his benefit. +Although frequently worsted in the conflict, nurses will often return +to the attack again and again and hour after hour, restraining, +reproving, forbidding, and even threatening. Nor do they see that they +are really goading the children into disobedience by their misdirected +efforts at enforcing discipline. Reproof, like punishment, loses all +its effect when it is too often repeated, and the child soon takes it +for granted that all he does is wrong, and that grown-up people exist +only to thwart his will, to misunderstand, to reprove, or even to +punish. + +In the nursery the word "naughty" is far too frequently heard. It is +naughty to do this, it is naughty to do that. There is no gradation in +the condemnation, and the child loses all sense of the meaning of the +word. He himself proclaims himself naughty almost with satisfaction: +his doll is naughty, the dog is naughty, his nurse and mother are +naughty, and so forth. In reality the little child is peculiarly +sensitive to blame, if he is not reproof-hardened. It is hardly +necessary to use words of blame at all. If he is asked kindly and +quietly to desist, much as we would address a grown-up person, and +does not, he can be made to feel that his conduct is unpopular by +keeping aloof from him a little, by disregarding him for the time +being, and by indicating to him that he is a troublesome little person +with whom we cannot be bothered. + +Any one who has had much to do with children will realise that, if +wrongly handled, they are apt to take a positive delight in doing what +they conceive to be wrong. There is clearly a delightful element of +excitement in the process of being naughty, of daring and of braving +the wrath to come, with which they are so familiar and for which they +care nothing at all. But the perverseness of which we are now speaking +has a different origin. It arises only when children are reproved, +appealed to, and expostulated with too often and too constantly. +Negativism is a symptom which is common enough in certain mental +disorders. The unhappy patient always does the opposite of what is +desired or expected of him. If he be asked to stand up he will +endeavour to remain seated, or if asked to sit he will attempt to rise +to his feet. Like many other symptoms of nervous disturbance which we +shall study later, this negativistic spirit is often displayed to +perfection by little children when the environment is at fault and +when grown-up people have too freely exercised authority. A mother, +anxious to induce her little son to come to the doctor, and knowing +well that her call to him to enter the room, as he stands hesitating +at the door, will at once determine his retreat to the nursery, has +been heard to say, "Run away, darling, we don't want _you_ here," with +the expected result that the docile child immediately comes forward. +To the doctor, that such a device should be practised almost as a +matter of course and that its success should be so confidently +anticipated, should give food for thought. It may shed light on much +that is to follow later in the interview. + +The question of punishment, like that of reproof, is beset with +difficulty. There are fortunately nowadays few educated mothers who +are so foolish as to threaten punishment which they obviously do not +intend to administer and which the child knows they will not +administer. It is clear that punishment must be rare or else the child +will grow habituated to it, and with little children we cannot be +brutal or push punishment to the point of extreme physical pain. It is +more difficult to say, as one is tempted to say, that all punishment +is futile and should be discarded. Probably mothers are like +schoolmasters in that no two schoolmasters and no two mothers obtain +their effects in exactly the same way or by precisely the same means. +Nor do all children accept reproof or submit to punishment in the same +way. Some make light of it and take a pleasure in defying authority. +Others are unduly cast down by the slightest adverse criticism. It is +generally true that extreme sensitiveness to reproof is a sign of a +certain elevation of character. Always we must remember that for a +mother to inflict punishment, whether by causing physical pain or +mental suffering, is to take on her shoulders a certain +responsibility. It is a serious matter if she has misapprehended the +child's act--if the sin was not really a sin, but only some perverted +action, the intention of which was not sinful, but designed for good +in the faulty reasoning of the child. A little girl, in bed with a +feverish cold, was found shivering, with her night-dress wet and +muddy. It was an understanding mother who found that her little +brother, having heard somehow that ice was good for fevered heads, had +brought in several handfuls of snow from the garden, not of the +cleanest, and had offered them to aid his sister's recovery. It need +hardly be said that punishment should always be deliberate. The hasty +slap is nothing else than the motor discharge provoked by the +irritability of the educator, and the child, who is a good observer on +such points, discerns the truth and measures the frailty of his judge. + +The frequent repetition of words of reproof and acts of punishment has +a further disadvantage that the older children are quick to practise +both upon their younger brothers and sisters. There is something wrong +in the nursery where the lives of the little ones are made a burden to +them by the constant repression of the older children. But although +set and artificial punishments are as a general rule to be used but +sparingly, the mother can see to it that the child learns by +experience that a foolish or careless act brings its own punishment. +If, for example, a child breaks his toy, or destroys its mechanism, +she need not be so quick in mending it that he does not learn the +obvious lesson. If the baby throws his doll from the perambulator, in +sheer joy at the experience of imparting motion to it, she need not +prevent him from learning the lesson that this involves also some +temporary separation from it. Throughout all his life he is to learn +that he cannot eat his cake and have it too. The use of rewards is +also beset with difficulties. Their coming must be unexpected and +occasional. They must never degenerate into bribes, to be bargained +for upon condition of good behaviour. Rewards which take the form of +special privileges are best. + +The æsthetic sense of children develops very early. From the very +beginning of the second year they take delight in new clothes, and in +personal adornment of all sorts. They show evident pleasure if the +nursery acquires a new picture or a new wall-paper. They have +pronounced favourites in colours. Even tiny children show dislike of +dirt and all unpleasant things. Personal cleanliness should be clearly +desired by all children. A sense of what is pleasant and what is +unpleasant should be encouraged. Any delay in its appearance is apt to +imply a backwardness in development of mind or of body. Only children +who are tired out by physical illness or by nervous exhaustion will +lie without protest in a dirty condition. + +Affection and the attempt to express affection appear clearly marked +even in the first year. Too much kissing and too much being kissed is +apt to spoil the spontaneity of the child's caresses. We must not, +however, expect to find any trace in the young child of such a complex +quality as unselfishness or self-abnegation. The child's conception of +his own self has but just emerged. It is his single impulse to develop +his own experience and his own powers, and his attitude for many +years is summed up in the phrase: "Me do it." We must not expect him +to resign his toys to the little visitor, or the little visitor to +cease from his efforts to obtain them. In all our dealings with +children we must know what we may legitimately expect from them, and +judge them by their own standards, not by those of adult life. We +cannot expect self-sacrifice in a child, and, after all, when we come +to think of it, obedience is but another name for self-sacrifice. If +the tiny child could possibly obey all the behests that are heaped +upon him in the course of a day by many a nurse and mother, he would +truly be living a life of complete self-abnegation. Surely it is +because the virtue of obedience, the virtue that is proclaimed +proverbially the child's own, is so impossible of attainment that it +is become the subject of so much emphasis. As Madame Montessori has +put it: "We ask for obedience and the child in turn asks for the +moon." Only when we have developed the child's reasoning powers, by +treating him as a rational being, can we expect him deliberately to +defer his wishes to ours, because he has learned that our requests are +generally reasonable. + + + + +CHAPTER III + +WANT OF APPETITE AND INDIGESTION + + +The mind of the child is so unstable and yet so highly developed, that +symptoms of nervous disturbance are more frequent and of greater +intensity than in later life. Only rarely and in exceptional cases do +certain symptoms, common in childhood, persist into adult life or +appear there for the first time, and then usually in persons who, if +they are not actually insane, are at least suffering from intense +nervous strain. We have already mentioned the symptom of negativism +and noted its occasional occurrence as an accompaniment of mental +disorder in adult life, and its frequency among children who are +irritable or irritated. Similarly, we may cite the digestive neuroses +of adult life to explain the common refusal of food and the common +nervous vomiting of the second year of life. Thus, for example, there +exists in adult life a disturbance of the nervous system which is +called "anorexia nervosa." A boy of nineteen was brought to the +Out-patient Department of Guy's Hospital suffering from this +complaint. He was little more than a skeleton, unable to stand, hardly +able to sit, and weighing only four and a half stones. His mother, +who came with him, stated that he had always been nervous, and that +lately, after receiving a call to join the army as a recruit, his +appetite, which had for some time been capricious, had completely +disappeared. In spite of coaxing he resolutely refused all food, or +took it only in the tiniest morsels, although at the same time it was +thought that he sometimes took food "on the sly." A careful +examination showed absolutely no sign of bodily disease. He was +admitted to a ward for treatment by hypnotic suggestion, but before +this could be begun he endeavoured to commit suicide by setting fire +to his bed. + +A girl of twenty-four years of age had become almost equally +emaciated. Constant vomiting had persisted for many years and had +defied many attempts at cure. It had even been proposed to perform the +operation of gastro-enterostomy in the belief that some organic +disease existed. In suitable surroundings and with the energetic +support of a good nurse, who spent much time and care in restoring her +balance of mind, the vomiting ceased, and she gained over two stones +in weight. Work was found for her in some occupation connected with +the War, and she left the Nursing Home to undertake this, bearing with +her four pounds which she had abstracted from the purse of another +patient. + +Those who have not opportunities of observing how all-powerful is the +effect of the mind upon the body, and especially perhaps upon the +process of digestion, may find it hard to believe that these +distressing symptoms and profound changes in the aspect and nutrition +of the patients were due entirely to mental causes and were symptoms +in accord with the attempted suicide or the theft of the money. In +nervous little children we shall not often find such complex actions +as suicide or theft, although they do occur, but combined with other +evidence of nervousness we shall meet commonly enough with a +persistent setting aside of appetite and refusal of food and with +continuous and habitual vomiting, from nervous causes. + +The experiments of Pawlow and others have explained the dependence of +digestion upon mental states. They show that even before the food is +taken into the mouth, while the meal is still in prospect, there has +been instituted a series of changes in the wall of the stomach, which +gives rise to the so-called psychic secretion of gastric juice. These +changes are preceded by the sensation of appetite, which is evoked not +by the presence of food in the stomach--for the food has not yet been +swallowed--but by the anticipation of it, by the sight and smell of +food, as well as by more complex suggestions, such as the time of day, +the habitual hour, the approach of home, and so forth. + +Emotional states of all sorts--grief, anger, anxiety, or +excitement--put a stop to the process or interfere with its action, so +that the sense of appetite is absent, and the taking of food is apt to +be followed by discomfort or pain or vomiting. No doubt good digestion +leads to a placid mind, but it is equally true that a placid mind is +necessary for good digestion. Therefore we civilised people, living +lives of mental stress and strain, try to increase the suggestive +force of our surroundings and to provoke appetite by all devices +calculated to stimulate the æsthetic sense. The dinner hour is fixed +at a time when all work and, let us hope, all worry is at an end for +the day. The dinner-table is made as pretty as possible, with flowers +and sparkling glass. We are wise to dress for dinner, that with our +working clothes we may put off our working thoughts. + +In the treatment of adult dyspepsia we seldom succeed unless we can +place the mind at rest. We may advise a visit to the dentist and a set +of false teeth, or we may administer a variety of stomach tonics and +sedatives, but if the mind remains filled with nameless fears and +anxieties we shall not succeed. + +In adult life the nervous person when subjected to excessive stress +and strain is seldom free from dyspeptic symptoms of one sort or +another, and what is true of adult life is even more true of +childhood, when the emotions are more poignant and less controlled. +Then tears flow more readily than in later life, and tears are not the +only secretions which lie under the influence of strong emotion. +Emotional states, which would stamp a grown man as a profound +neurotic, are almost the rule in infancy and childhood, and may be +marked by the same physical disturbances--flushing, sweating, or +pallor, by the discharge of internal glandular secretions as well as +by inhibition of appetite, by vomiting, gastric discomfort, or +diarrhoea. Naturally enough, mothers and nurses are wont to demand a +concrete cause for the constant crying of a little child, and +teething, constipation, the painful passage of water, pain in the +head, or colic and indigestion are suggested in turn, and powders, +purges, or circumcision demanded. There can be no doubt that nervous +unrest is capable of producing prolonged dyspepsia in infancy and +childhood--a dyspepsia which, while it obstinately resists all +attempts to overcome it by manipulation of the diet, is very readily +amenable to treatment directed to quiet the nervous system. + +Where a primary dyspepsia exists for any length of time, the growth +and the nutrition of the child is clearly altered for the worse. The +character of the stools, their consistency, smell, and colour, is apt +to be changed because the bacterial context of the bowel has become +abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, +prolapse of the rectum, and infection with thread-worms are common +complications. No doubt children with primary dyspepsia are often +nervous and restless, and the elements of infection and of neurosis +are frequently combined. Yet often we meet with cases in which the +gastric or intestinal disturbance comes near to being a pure neurosis. +The nutrition, then, seldom suffers to any very great extent, or to a +degree in any way comparable to that which is characteristic of +dyspepsia from other causes. Emaciation, wrinkling of the skin, +dryness and falling out of the hair, decay of the teeth, are not as a +rule part of the picture of nervous dyspepsia. The child may be slim +and thin and nervous looking, but as a rule he is active enough, with +a good colour and fair muscular tone, so that one has difficulty in +believing the mother's statements, which are yet true enough, as to +the trouble which is experienced in forcing him to eat, or as to the +frequency of vomiting. + +In early childhood the difficulty of the refusal of food often passes +or diminishes when the child learns to feed himself with precision and +certainty. To teach him to do so, it is not wise to devote all our +attention to making him adept at this particular task. The fault is +that the brain centres which control the movements of hands, mouth, +and tongue have not been developed, because his activities in all +directions have not been encouraged. It is much less trouble for a +nurse to feed a little child than to teach him to feed himself, and if +he is not given daily opportunities of practice he will certainly not +learn this particular action. But the fault as a rule lies deeper. The +child who cannot feed himself cannot be taught until fingers and brain +have been developed in the thousand activities of his daily routine, +by which he acquires general dexterity. A child who is still too young +to feed himself is learning the dexterity which is necessary as a +preliminary in every action of the day. If he can carry the tablecloth +and the cups and saucers to the tea-table, imitating in everything the +action of his nurse, it will be strange if he does not also imitate +her in the central scene, the actual eating of the food. If, on the +other hand, he is waited upon hand and foot, if he is restrained and +confined, sitting too much passively, now in his perambulator, now in +his high chair, now on his nurse's lap, his imitative faculties and +his tactile dexterity alike remain undeveloped. The child who is slow +in learning to feed himself shows his backward development in every +movement of his body. One may note especially the stiff, +"expressionless" hands, indicating a general neuro-muscular defect. I +have seen many children of eighteen months or two years of age in whom +the movements necessary for efficient mastication and swallowing had +failed to develop satisfactorily. In some a pure sucking movement +persisted, so that when, for example, a morsel of bread or rusk was +put in the child's mouth, it would be held there for many minutes and +submitted only to suction with cheeks and tongue. Attempts to swallow +in such a case are so incoordinate that they give rise frequently to +violent fits of choking, which distress the child and produce +resistance and struggling, while at the same time they alarm the +mother or nurse so much that further attempts to encourage the taking +of solid food are hastily and for a long time abandoned. In this +helpless condition the other factors which tend to develop what we +have called negativism have full play. The want of imitation and the +lack of dexterity is not the sole or perhaps the main cause of the +child's refusal of food and of the apparent want of appetite, but it +is the cause of the failure to learn to feed himself, which places +him in a condition which is peculiarly favourable to the operation of +other factors. If only we can teach the child to feed himself, the +difficulties of the situation become much less formidable. + +The first of the factors which encourage the persistent refusal of +food is the extreme susceptibility of the child to suggestion. A +particular article of diet may be refused on one occasion, perhaps in +pique, because another more favoured dish was hoped for or expected, +or perhaps because the taste is not yet familiar. Then if on this +occasion a struggle for the mastery is waged, and a painful impression +is made on the child's mind connecting this particular dish with +struggling and tears, from that day forward the child may persistently +refuse it on every occasion it is offered. Matters are made worse if +the nurse, anticipating refusal, attempts to overcome the resistance +by peremptory orders, or by excessive praise extolling the delicious +flavour with such fervour that the child's suspicions are at once +aroused. Previous experience has made him connect these excessive +praises with articles which have aroused his distaste. If these fads +and fancies on the part of the child are to be avoided, it is +essential that we should do nothing to focus his attention on his +refusal. It is better that his dinner should be curtailed on one +occasion than that taste and appetite should be perverted perhaps for +years. Every nurse or mother should cultivate an off-hand, detached +manner of feeding the child, and should patiently continue to offer +the food without uncalled-for comments or exhortations. Let her always +remember the force of suggestion on the child's mind, and that a +confident manner which never questions the child's acceptance will +meet with acceptance, while a hesitating address, from fear of the +impending refusal, will be apt to meet with refusal. Sometimes a still +worse fault manifests itself, when nurse and mother speak before the +child of the smallness of his appetite, and of his persistent refusal +of this or that article of diet. The suggestion then acts still more +powerfully on his mind. He is aware that the whole household is +distressed by his peculiarity, and he grows to identify it with his +own individuality, and to regard himself with some satisfaction as +possessing this mark of distinction. If there is any difficulty of +this sort it is often directly curative to reverse the suggestion and +to speak before him of his improving appetite, and to say that he +begins every day to eat better and better, even if to do so we have to +break a good rule never to say to the child what is not strictly true. +Or once or twice we may take his plate away before he has finished, +saying positively that he has eaten so much that he must eat no more. +If in spite of every care antipathies to certain articles of food +appear and persist, we must be content to bide our time. When the +child grows of an age to reason, we should seize every opportunity to +make him feel that his persistent refusal is a little ridiculous and +childish. Little by little the seed is sown, and will germinate till +one day we shall note with surprise that he has taken of his own +accord that which he has neglected for so long and with such +obstinacy. + +But the force which is acting most strongly in producing this refusal +of food is the force of which we have spoken in a previous +chapter--the force which results in negativism, the force which is in +reality the habit of opposition, the love of power, and the desire to +attract attention. Here again the refusal of food, if due to this +cause, is never the sole manifestation of the fault. Just as the delay +in learning to swallow and to chew properly and to feed himself is +part of a general want of dexterity and capacity manifested in all his +actions, so it will seldom happen that the child's anxiety to oppose +is only seen at meal-times. Watch a nervous child in the nursery +before the dinner hour. He is cross and restless and inclined to cry. +The nurse hands him a doll, and he throws it away saying, "No, no +doll." At the same moment he may catch sight of his ball, and it too +is violently rejected, "No, no ball." Everything in turn is treated in +the same way. Finally he falls upon his nurse, crying and beating her +with his hands, saying, "No, no Nurse." If that long-suffering woman +at that moment summons him to dinner, it will be strange indeed if his +attitude is not "No, no dinner," and "No, no" to every mouthful +offered him. How strong this love of opposition may be is illustrated +by the case of a little boy who was brought to me for refusal of food. +Three weeks before, he had been taken in a motor-car to his +grandfather's to midday dinner on Sunday, when his absolute refusal of +food had spoiled the day and had occupied the attention and the +efforts of the whole party. Doubtless he had enjoyed himself, for +three weeks later, when he caught sight of the car which was to bring +him to me, and which he had not seen in the interval, he at once said, +"Not eat my dinner." This child's father told me that the sight or +sound of the preparation of a meal was enough to bring on a paroxysm +of opposition. Now this force of opposition, as we have seen, only +develops into a serious difficulty when the child's own will has been +opposed too much, when authority has been too freely exercised, and +when the child has been urged and entreated and reproved with too +great frequency. His opposition grows with all counter-opposition. And +he is not really naughty, only irritable and restless from the +thwarting of his natural impulses, and unable to express his thoughts +and desires. Negativism will not often confine itself to meal-times. +It will show clearly in all the actions of the child, and to get him +to eat well and freely we must so change our management of him that +negativism disappears or at least diminishes. There is no other way. +No entreaty, no force, no threats of force will ever succeed, but will +only make him worse, and, since negativism is due to mental unrest, +the struggles and crying will only perpetuate the cause. The one way +to banish negativism and overcome the opposition is to cease to +oppose, and to practise this aloofness not so much at meal-times, for +somehow by patience the child must be got to take his food, but in all +our conduct to him. Repression and reproof, and thwarting of the +child's will, and coaxing and entreaty must cease. There is no fear +that we shall thereby make the child unduly disobedient. We have +already, in another chapter, decided that negativism is not strength +of will on the part of the child which must be broken, but is the +result of constant attempts to oppose his nature, and the consequent +nervous unrest. If we cease to oppose, the symptoms will tend rapidly +to disappear, the child will become busy and contented and happy in +his play, and we shall hear no more of his refusal of food. If +sometimes it recurs for a week or two, we shall know how to deal with +it. + +In children, as with us, periods of nervous unrest and unhappiness are +apt to recur in a sort of cycle. This cyclical character of mental +disturbance is often a marked feature. We see it in epilepsy and +in what the French have called Folie Circulaire. We see it in the +dipsomaniac, in the intermittency of his craving for drink and of his +periodical outbursts, and we see it in ourselves in those periods of +depression which recur so often, we know not why. Little children too +sometimes get out on the wrong side of their beds, and never get right +the whole long day. Their own experience of the vagaries of mental +states should lead mothers to be indulgent to the children in their +days of cloud and to be particularly careful not to goad them by +well-intentioned efforts into bursts of naughtiness and passion, each +one of which tends to perpetuate the condition and increase the +nervous unrest. We know how closely dependent is the sensation of +appetite upon emotional states, and we must do all in our power--and +the task is sometimes one of real difficulty--to keep the child's mind +sufficiently at rest to preserve the healthy desire for food +unimpaired. If there is no sign of appetite, but every sign of +restlessness and irritability, we must seek in the management of the +child until we find the fault. + +If food is taken mechanically and without appetite, if the preliminary +changes in the stomach wall which are necessary for adequate digestion +do not take place, but are inhibited by the mental unrest, the meal is +apt to be followed by gastric pain and discomfort, or, more commonly +with children, the stomach may promptly reject its contents. At the +worst, nervous vomiting of this sort may follow almost every meal, +although, again, it is curious to note how little, comparatively +speaking, the nutrition of the child suffers. The vomiting too, as in +adults, comes very near being a voluntary act, and mothers and nurses +will often remark that they get the impression that it can be +controlled at will. If once the diagnosis is made that the want of +appetite or the vomiting is of nervous origin, the treatment of the +condition is clear. Sedative drugs directed towards quieting the +nervous excitability may be of service, but tonics, appetisers, +laxatives, and drugs with a direct action on the stomach will have but +little effect. Nor is there as a rule anything to be gained by +modifying the diet or by excluding this or that article of food. The +frequency of the vomiting is such that it is apt to have brought +discredit one after the other upon almost every article of food which +the child can take, with the result that many useful and necessary +foods have been abandoned for long on the ground that they are the +cause of the dyspepsia. A permanent cure will only be effected when +the faults of environment have been overcome, when the cause of the +nervous unrest has been removed, and when the child's mind is at +peace. + +Nervous vomiting of this kind is not difficult to control, if those in +charge of the children can be made to understand that the cause lies +in the anxiety which they themselves show before the child, increasing +his own apprehension or adding to his sense of power or importance. +Once the child is convinced that his conduct excites no particular +interest, the vomiting soon ceases. In more than one instance, +vomiting which has persisted for many months has stopped at once after +the matter has been fully explained to the parents. In the most +inveterate case of this sort which has come under my notice, the child +was regularly sick as soon as he caught sight of a white cloth being +laid on the table for meals. Yet even this child never vomited when he +was under the charge of a particular nurse who had to return more than +once to the family, and on each occasion was successful in breaking +the habit. + + + + +CHAPTER IV + +WANT OF SLEEP + + +So far, almost all that has been written--and there has been a great +deal of unavoidable repetition--has been devoted to an attempt to +determine the causes which lead the child to refuse food and the +methods which we adopt to prevent or overcome the difficulty. Other +neuroses may be studied in less detail, because they depend for their +existence upon the same causes. For example, the habit of refusing +sleep, which is as common and almost as distressing as the habit of +refusing food, depends both upon a perversion of suggestion and upon +the phenomenon that we have called negativism. + +If struggling and crying has occurred upon a series of nights, the +child comes to associate his bed not with sleep but with tears. If a +mother values her peace of mind, if she would spare herself the +discomfort of hearing her child sob himself nightly into uneasy sleep, +she must be wary how this all-important event of going to bed is +approached. With a nervous and restless child the preliminaries of +preparing for bed must be managed carefully and tactfully. The hour +before bedtime is almost universally the most interesting of the +whole day for the child. Then the baby, with his best frock on, and +books and toys, is the centre of interest in the drawing-room, till +the clock strikes and the nurse appears at the door. Suddenly it is +all over, and inexorable routine sends him off to bed. The good nurse +will give the child a little time to recover from the shock of her +arrival, and will not hurry him. She knows that his little mind is +slow to act, and that he must be led gradually to face a new prospect. +If she hurries him, catching him up in her arms from the midst of his +unfinished pursuits, resistance and tears are almost sure to follow, +and the difficult task of the day--the putting to bed--has made the +worst possible start. When this has happened on one or two successive +evenings, the habit of resistance to going to bed becomes fixed, and, +like all bad habits, is difficult to break. A nurse who has a way with +children will arouse his interest in a new pursuit, in which he can +play the chief part, the putting away of his picture books and toys. +If he is too small to carry his own chair or table to its allotted +place in the room, at least he can show his learning by pointing out +the spot. In the waving of good-byes he is expert and takes a +legitimate pride, and upstairs he has learnt that there are new +delights. He himself can turn on the taps in the bathroom, and he can +set every article in the proper place ready for use. All children love +their bath, and if interest and good temper has been so far preserved, +without a break, it will be ill-fortune if even the drying process is +not carried off without a hitch. Afterwards, for a little, nervous +babies, whose brains still teem with all the excitements of the day, +are best left to sit for a few moments by the nursery fire, while the +nurse puts all the garments one by one to bed. Each as it goes to rest +will be greeted by him with cheerful farewells; and so does the force +of suggestion act, till the central figure himself plays his part in +the scene, of which he feels himself the controller and director, and +climbs to bed. But if there has been a hitch anywhere, if the bugbear +of negativism has appeared, if he has been scolded or coaxed or +repressed too much and there have been tears and struggles, then going +to bed is a poor preparation for instant and quiet sleep. + +With excitable, highly-strung children, the best laid plans and the +most tactful nurse will not always succeed, and to place him in his +cot is to provoke a storm of angry refusal and resistance. There are +mothers who believe that the best way is then to turn out the light +and leave the child to cry himself to sleep. This is a point on which +no one can lay down rules which are applicable for all children. It +may sometimes succeed, and the child may reason correctly and in the +way we wish him to reason, deciding that the game is not worth the +candle and so give it up. But with nervous, highly-strung children I +doubt if this Spartan conduct is commonly successful. Often if the +attempt is made, the troubled mother, listening to all these +heart-breaking sobs, can bear it no longer, and goes back to the side +of the cot to soothe and persuade him. Then certainly the longer she +has restrained her natural inclination, the longer the child has +sobbed himself into a pitiful little ball of perspiration and tears, +the more difficult will be her task in quieting him, the stronger will +be the impression formed on the child's mind, and the greater will be +the suggestion which will act under the same circumstances to-morrow. +Children who fall a prey to this uncontrolled crying, cry on because +they cannot stop when they have begun. They do not then cry purposely +or with a fixed intention, desiring to attain some object. They cry +because their minds are not at rest, but are irritated and overwrought +by the happenings of the day. We decided that it was useless to +attempt by exhortations at meal-times to induce a nervous child to eat +who habitually refuses food, and that we can only cure the condition +by eliminating from his daily life the elements of repression and +opposition which provoke the counter-opposition. And we must seek the +same solution in this other difficulty of the refusal of sleep. It is +useless to attempt to treat the symptom of refusal of sleep and to +leave the cause of that symptom still constantly in action. + +If, in spite of our care to avoid unrest and irritation of the child's +brain, sleep is refused, as may often happen, it is, as a rule, wise +to cut short the crying if we can, before a vicious circle has been +formed and the unrest has been intensified by the emotional storm. It +is useless with little children to urge them to go to sleep or to +coax. It is not usually wise to leave the child for a little and then +to return. Each time the child is left, each time the mother or nurse +returns, the crying bursts forth again with renewed force and vigour. +It is at least one good plan with a little child to turn the light +out, and, treating the whole incident in the most matter-of-fact way +possible, lightly to stroke his head or pat his back rhythmically +without speaking. With older children, if the crying is more +purposeful and less emotional, the mother may busy herself for a +little with some task in the room, ostentatiously neglecting the storm +and making no reference to it. If she speaks to the child at all she +should do so in a matter-of-fact way, referring lightly to other +matters. If only she can convince him that his conduct is a matter of +indifference to her, the victory is won. It is because the child knows +so well that his mother does care that he so often has the upper hand. +It is not difficult to distinguish between a true emotional storm and +the tyrannous cry of a wilful child who demands his own way. + +Light and broken sleep is a common accompaniment of a too excitable +and overstimulated brain. The placid child, who eats well, plays +quietly, and does not cry more than is usual, as a rule sleeps so +soundly that no ordinary sounds, such as conversation carried on in +quiet tones in his neighbourhood, have the power to waken him. When he +wakes, he does so gradually, perhaps yawning and stretching himself. +The nervous child may move at the slightest sound, or with a sudden +start or cry is wide awake at once. A hard mattress should be chosen +without a bolster, and with only a low pillow. Flannel pyjamas, which +cannot be thrown off in the restless movements of the child, should be +worn. The temperature of the room should be cool, and the air from the +open window should circulate freely, while draughts may be kept from +striking on the child by a screen. All the sensations of the nervous +child are abnormally acute. Thus, for example, an itching eruption, or +tight clothing, will produce an altogether disproportionate reaction, +and may result in a frenzy of opposition. Especially such a child is +sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool +rooms and warm but light and porous clothing are essential. An +electric torch, which can be flashed on the child for an instant, will +assist the mother or nurse to make sure that the child has not thrown +off all the bedclothing. + +Sometimes want of sleep is accounted for by a real want of physical +exercise. Town children especially are apt to suffer from their +limited opportunities of running freely in the open. It is often +considered enough that the child seated in his perambulator should +take the air for three or four hours daily, while much of his time +indoors as well is devoted to sitting. It is necessary for his proper +development that he should have opportunities of daily exercise in the +open. If for any reason this is not always practicable, a large room, +as free as possible from furniture, should be chosen, with windows +thrown wide open, in which the child may romp until he is tired. + +It is rare for children of two or of three years of age, whose case +we are now considering, to be troubled by bad dreams, nightmares, or +night-terrors. If these should occur, obstructed breathing due to +adenoid vegetations is sometimes at work as a contributory cause. + +Finally, we should always remember that refusal of sleep is, for the +most part, caused and kept up by harmful suggestions derived from +mother and nurse, who allow the child to perceive their distress and +agitation, who speak before the child of his habitual wakefulness, who +unwittingly focus his attention on the difficulty. It is cured in the +moment that the suggestion in the child's mind is reversed, in the +moment when he comes to regard it as characteristic of himself not to +make a fuss about going to bed, but to sleep with extraordinary +readiness and soundness. Let every one join together to produce this +effect. Let the suggestion act strongly on his mind that all these +troubles of sleeplessness are diminishing, that night after night sees +an improvement, and soon his reputation as a good sleeper will be +established, and, as always with children, it will be rigidly adhered +to. + +In assisting to break the habit of sleeplessness, and in the process +of altering the character of the suggestions which act on the child's +mind, we can be of the greatest assistance to the mother by +prescribing a suitable hypnotic. As to whether it is right in insomnia +in childhood to prescribe depressant drugs is a question on which very +various opinions are held. That it is wrong and probably ineffective +to trust entirely to the drugs is certainly true, but as a temporary +measure, to break the faulty suggestion and the bad habit, their use +is both legitimate and successful. The dose required in children +relatively to the adult is much smaller. In grown people, some +specific distress of mind, whether real or imaginary, may suffice to +resist very large doses of hypnotic. In children it is rare to find +the same resistance, and comparatively small doses have a very +constant effect. With deeper and more refreshing sleep, the conduct of +the child during the day almost always changes for the better. A sound +sleep, for a few nights in succession, will produce apparently quite a +remarkable change in the whole disposition of the child. When good +temper and interest take the place of fretfulness and restlessness, we +may confidently expect that the symptom of sleeplessness will begin to +abate. Sleeplessness by night and fretfulness by day form a vicious +circle, and attempts must be made to break it at all points. + +Chloral occupies the first place as a hypnotic for young children. In +combination with bromide its effects are wonderfully constant and +certain. Two grains of chloral hydrate and two grains of potassium +bromide with ten minims of syrup of orange, given just before bedtime, +will bring sound sleep to a child of a year old. At three years the +dose may be twice as great, and three times at six years. It is seldom +that other means are required. Aspirin for children seems relatively +without effect. For children who are both sleepless and feverish, a +grain of Dover's powder, and a grain of antipyrin, for each year of +the child's age up to three, is very helpful. Lastly, if chloral and +bromide cannot break the insomnia, and the condition of the child is +becoming distressing, we can almost always succeed if we combine the +prescription with an ordinary hot pack for twenty minutes. + + + + +CHAPTER V + +SOME OTHER SIGNS OF NERVOUSNESS + + +HABIT SPASM + +Next to refusal of food and refusal of sleep perhaps the most frequent +manifestation of nervous unrest is provided by the group of symptoms +which we may call, with a certain latitude of expression, Habit +Spasms. By a habit spasm is meant the constant repetition of an action +which was originally designed to produce some one definite result, but +which has become involuntary, habitual, and separated from its +original meaning. The nervous cough forms a good example of a habit +spasm. A cough may lose its purpose and persist only as a bad habit, +especially in moments of nervousness, as in talking to strangers, in +entering a room, or at the moment of saying "How do you do" or +"Good-bye." Twitching the mouth, swallowing, elongating the upper lip, +biting the lips, wrinkling the forehead so strongly that the whole +scalp may be put into movement, and blepharospasm are all common +tricks of little children which may become habitual and uncontrolled. +In worse cases there may be constant jerking movements of the head, +nodding movements, or even bowing salaam-like movements. In mild +cases we may note hardly more than a restless movement of mouth or +forehead, or constant plucking or writhing of the fingers whenever the +child's attention is aroused, when he is spoken to, or when he himself +speaks. In nervous children these movements, which should properly be +confined to moments of real emotional stress, become habitual, and are +displayed apart from the excitement of particular emotions. Whatever +their intensity, habitual and involuntary movements of this nature +should not be overlooked, and should be regarded as evidence of mental +unrest. They do not commonly appear during the first or second years +of the child's life. They are more frequent after the age of five, but +they may begin to be marked as early as the third year. With refusal +of food and refusal of sleep they form the three common neuroses of +early childhood. + +Two of the three qualities which we have mentioned as characteristic +of the child's mind are concerned in the causation of habit spasm. In +the early stages the movement is sometimes due to imitation, but the +susceptibility of the child to suggestion plays the chief part in +determining its persistence. It is an interesting speculation how far +tricks of gesture, attitude, or gait are inherited and how far they +are acquired by imitation. A child by some characteristic gesture may +strikingly call to mind a parent who died in his infancy. A whole +family may show a peculiarity of gait which is at once recognisable. +It is told of the son of a famous man, who shared with his father the +distinctive family gait, that when a boy his ears were once boxed by +an old gentleman who chanced to observe him hurrying to overtake his +parent, and who resented what he took to be an act of impertinent +caricature. In the reproduction by the child of the habitual actions +of his parents, heredity is largely concerned, but imitation too plays +its part. In habit spasm the force of imitation is clearly seen. A +child who has developed a habit spasm of one sort or another will +readily serve as a model to other children. The malady will sometimes +spread through a school almost with the force of a contagious +disorder. A child affected in this way may prove an unwelcome guest. +The little visitor with a trick of contorting his mouth and grimacing +is apt to leave his small host an expert in faithfully reproducing the +action. A cough that is genuine enough in one member of the family may +produce a crop of counterfeits in brothers and sisters. + +The force of suggestion acting upon the child's mind can clearly be +traced. Once his attention is focused upon the particular movement by +unwise emphasis on the part of the parents, he loses the power to +control its occurrence. This trio of common neuroses--refusal of food, +refusal of sleep, and habitual involuntary movement--grows only in an +atmosphere of unrest and apprehension. Parents and nurses anxiously +watch their development. They are distressed beyond measure to note +their steady growth in spite of every attempt which they make to +control or forbid them. And of all this unrest and unhappiness the +child is acutely conscious. The whole household may become obsessed +with the misfortune which has befallen it, and the mother, losing all +sense of proportion, feels that she cannot regain her peace of mind +until it has been overcome. The child is in need of mental and moral +support from those around him, and all that he finds is an openly +expressed apprehension and sense of impotence. Even grown-up people, +when their nerves are on edge, are apt to be obsessed by +uncontrollable impulses or by vague and nameless apprehensions, and +surely all have learnt the support they gain from contact and +conversation with some one strong and sane, who treats their worries +in such a matter-of-fact way that immediately they lose their power +and become of no account. The child with habit spasm cannot control +these movements. The more he is reproved or entreated, the less able +does he find himself to hold them in check. He does not wish them to +continue. He has lost control of what he once controlled, and the +realisation of this is not pleasant, and may be alarming to him. Yet +when unconsciously he looks to his mother for support, he finds in her +open dismay that which serves only to increase his uneasiness. She +must subdue her own feelings and give the child strength. If she +treats the whole thing in a matter-of-fact way, as a temporary +disturbance which is of no importance in itself, and only has meaning +because it implies that the brain has been over-stimulated, she will +no longer exercise a prejudicial effect on the child. If the bad habit +is taken as a matter of course, if too much is not made of it, if the +child is encouraged to think that nobody cares much about it at all, +then recovery will soon take place. It goes without saying that habit +spasms and tics of all sorts are made worse by excessive emotional +display and by nervous fatigue. On the other hand, if the child +becomes absorbed in some interesting occupation, the movements will +disappear for the time being. + + +AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING + +At a somewhat earlier age than that in which habit spasms become +common, and before bed wetting appears as a formidable difficulty, we +meet with another group of habitual actions which yet retain their +voluntary character. Among such habitual actions are thumb sucking, +thigh rubbing, and air swallowing. If the child is old enough to +express himself on the subject, he will explain that these actions are +performed because of the satisfaction derived from them, because it is +"comfy" and "nice." Even if the child is too small to speak, the +expression is that of beatitude and content. These actions are not +confined to nervous children, and their occasional practice need not +be taken to imply that there is any strong element of nervous +overstrain. It is only when the action is repeated with great +frequency and persistence, and when signs of irritation ensue if +gratification is not obtained, that we are justified in classing it +among the symptoms of mental unrest. + +The second of these actions, thigh rubbing, is found for the most +part in little girls, and inasmuch as it consists of a stimulation of +the sexual organs sometimes causes much distress to the parents. It is +in reality a habit of small importance unless exercised with very +great frequency. It is, of course, not associated in the child's mind +with any sexual ideas, and is of precisely the same significance as +the other two actions of the same class. Children who can speak will +refer to it openly without any sense of shame. As a rule the action is +performed in a half-dream state, that condition between sleeping and +waking which is found when the child is lying in the morning in her +cot or in her perambulator after the midday nap. The child's attention +should not be focused on the symptom. She should lie on a hard +mattress, and when she wakes in the morning she should either leave +her cot at once or she should be roused into complete wakefulness by +encouraging her to play with her toys. Little children should be +taught to sleep with their hands folded and placed beside the cheek. +If the movement occurs on going to sleep, it is best left alone and +completely neglected. As a rule each child has his or her own +favourite action of this class, and they are seldom combined in the +same child. If thigh rubbing is very constant and obstinate and does +not yield to the measures suggested, it may even sometimes be a +successful manoeuvre to substitute the thumb-sucking habit in the +expectation that this less distressing habit may eject the other more +objectionable action. As a rule, however, a wise neglect and careful +watching during the drowsy condition that follows sleep in a warm bed +will succeed in stopping the practice of thigh rubbing before the end +of the second or third year. Apparatus designed to restrain movement +of the child's legs or blistering the opposed surfaces of the thighs +are both of no effect. They have indeed the positive disadvantage that +they focus the child's attention on the practice. The habit ceases +only when the child has forgotten all about it, and these devices +serve only to keep it in remembrance. The same may be said of any +system of punishments. Further, we cannot always have the child under +observation, and at some time or other opportunity will be found for +gratification. Of older children, in whom self-control and a sense of +honour can be cultivated, I am not here speaking. + +Air swallowing is less common than thigh rubbing, but belongs to the +same group of actions and takes place in the same drowsy condition. +The child will rapidly gulp down air which distends the stomach, and +is then regurgitated with a loud sound. Thumb sucking seldom +distresses the mother to the same extent, and the proper attitude of +tolerance is adopted towards it. If much is made of it, it is +astonishing how persistent the habit may become, surviving all +attempts to forbid it, to break it by rewards or punishments, or to +render it distasteful by the application of a variety of ill-tasting +substances smeared on the offending digit. + +PICA AND DIRT EATING + +Certain other bad habits will become ingrained if attention is called +to them, because of that curious spirit of opposition which +characterises little children, and because of their susceptibility to +suggestion. Some children will constantly pluck out hairs and eat +them, or will devour particles of fluff drawn from the blankets. +Others will seize every opportunity to eat unpleasant things, such as +earth, sand, mud, or dirt of any sort. All tricks of this sort are +best neglected and treated by attracting the child's attention to +other things. In adult life they are associated with serious mental +disturbance, in early childhood they are of little account, or at most +suggest a certain nervousness which may be due to nervous irritation +from faults of management which we must strive to correct. + + +CONSTIPATION + +As has been already mentioned, much of the common constipation of the +nursery is due to neurosis. The excessive concentration of the nurse's +thoughts on this daily question communicates itself to the child. The +difficulty is emphasised, and an attempt is made to substitute will +power for forces of suggestion which are at once inhibited by +concentration of the mind upon the process. Here also, just as in the +refusal of food, a further stage of "negativism," that is, of active +resistance with crying and struggling, is reached, so that complaint +may be made by the mother that defæcation is painful. The same +negativism may be shown in micturition, and mothers will give +distressing accounts of the suffering of the child during the passing +of water. + + +BREATH-HOLDING AND LARYNGISMUS STRIDULUS + +In some children, in the first two years of life, we find a definite +and measurable increase in the irritability and conductivity of the +peripheral nerves. The strength of current necessary to produce by +direct stimulation of the nerve a minimal twitch of the corresponding +muscle may be many times less than the normal. Of this heightened +irritability of the nervous system, to which the name "spasmophilia" +has been given in America and on the Continent, the most striking +symptom is a liability alike to tetany or carpo-pedal spasm, to +generalised convulsions, and to laryngismus stridulus. In addition, in +most cases it is generally possible to demonstrate the presence of +Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a +visible twitch of the facial musculature, especially of the +orbicularis palpebrarum or of the orbicularis oris, in response to a +gentle tap administered over the facial nerve in front of the ear. +Trousseau's sign is the production of tetany by applying firm and +prolonged pressure to the brachial nerve in the upper arm. The +ætiology of spasmophilia is still a matter for dispute, but the +evidence which we possess is in favour of the view that we have here +to deal with a disturbance of calcium metabolism. The calcium content +both of the blood and of the central nervous system has been shown to +be much lowered. It is in keeping with this that clinically we note +how frequently spasmophilia and rickets occur in the same child. In +some families the condition recurs through many generations. + +For our present purpose--the examination of some common neuroses of +nursery life--it would be out of place to enter into a detailed +consideration of this disorder of spasmophilia as a whole. The symptom +of laryngismus stridulus--the so-called breath-holding--alone need +concern us, and that for a special reason. The spasm of the glottis is +produced under the influence of any strong emotion--in anger, for +example, or in fear, in excitement or in crying for any reason. To +control or prevent it we must direct attention not only to the +condition of spasmophilia, but also to the management of the children +who are always excitable and emotional. In these children every burst +of crying, however produced, whether by a fall, by a fright, by the +entrance of a stranger, or by a visit to a doctor, is apt to be +ushered in by a long period of apnoea, due to spasm of the glottis +and of the diaphragm. The first few expirations are not followed by +any inspiration. For several seconds the silence may be complete, +while the child steadily becomes more and more cyanosed, or the body +may be shaken by incomplete expiratory movements and strangled cries +which are suppressed because the chest is already in a position of +almost complete expiration. In the worst cases, when the apnoea +lasts a very long time, there may be convulsive twitching of the +muscles of the face, or the attack may even terminate in general +convulsions. Very occasionally the spasm is actually fatal. In all +fatal cases which have come to my notice the child at the moment of +death had been alone in the room. I have met with no fatal case where +the baby could be picked up and assisted. As a rule, therefore, the +cause and mode of death must be conjectural, but when an infant is +found dead in its cot unexpectedly, it would seem likely that it has +waked from sleep with a sudden start, become excited, and, about to +cry, has been seized by the fatal spasm. In two instances reported to +me a cat had been found in the room with the dead child, and it was +suggested that the animal had lain upon the child's face. Both these +children, however, were vigorous and capable of powerful movements of +resistance. I think it more likely that the cat may have awakened them +in fright, and that the emotional excitement, giving rise to the +spasm, was the cause of the suffocation. That the apnoea in these +extremely rare instances should end fatally produces a difficult +position for the doctor. It need hardly be said that the seizures are +alarming to the parents. For the sake of great accuracy in the +statement of our prognosis are we to add a hundred times to the +mother's alarm by stating the possibility of death? In each case we +must use our own judgment. I believe that in a child over a year old +the risk is almost negligible. + +Fortunately in all save the rarest possible instances the apnoea +yields and a deep inspiratory movement follows. As the air rushes past +the glottis, which is still partially closed, a sound recalling the +whoop of pertussis is heard. Often this recurs throughout all the +burst of crying which follows, and each inspiration is accompanied by +a shrill stridulous sound. With the re-establishment of respiration +the cyanosis rapidly fades, to be succeeded in some cases by pallor +and perspiration. + +It need hardly be said that we should do all in our power to prevent +these alarming and distressing attacks. Each seizure predisposes to a +repetition. In some children we notice that months and even years +after an attack of whooping-cough, a slight bronchial catarrh may be +sufficient to bring back the characteristic cough. In laryngismus in +the same way we may suppose that the reflex path is made easy and the +resistance lowered by constant use. Fortunately the spasms are not +usually difficult to control. Calcium bromide, in doses of from two to +four grains, according to age, three times daily, is generally +successful with or without the addition of chloral hydrate in small +doses. At the same time we must endeavour in every way possible to +keep the child calm, by paying close attention to nursery management. +The child with spasmophilia is as a rule excitable and easily upset, +and although calcium bromide is a drug which offers powerful aid it is +not able to achieve its effect unless we are able at the same time to +guarantee a reasonable immunity from emotional upsets. It is for this +reason that I have included some description of laryngismus, although +its origin is undoubtedly very different from that of the other +disorders of conduct which we have examined. + + +MIGRAINE AND CYCLIC VOMITING + +The ætiology of cyclic or periodic vomiting in childhood is not yet +completely understood. We do not know how far it is dependent upon +disturbance of the liver, and it is still disputed whether the +acidosis which accompanies it is the cause or the result of the +profuse vomiting. Into these difficult questions we need not at the +moment enter. It is enough in the present connection to recognise that +the great majority of children who suffer from cyclic vomiting are +sensitive, excitable, and nervous, and that every one is agreed that +the nervous system is intimately concerned in its causation. + +A close association between cyclic vomiting in children and that form +of periodic headache known as migraine has often been observed. It is +sometimes found that one or both parents of a child with cyclic +vomiting suffer habitually from migraine. In a few instances the one +condition has been observed to be gradually replaced by the other, the +child with cyclic vomiting becoming in adult life a sufferer from +migraine. There is indeed much which is common to the two conditions. +The periodic nature of the seizure, often following a time when the +general health and vigour appear to have been at their optimum, the +extreme prostration, and the comparatively sudden recovery are found +in both. In the cyclic vomiting of children, it is true, little +complaint is made of headache, the visual aura is absent, and the +vomiting is invariably the most prominent symptom. + +Cyclic vomiting seldom occurs before the fourth year. It is +characterised by sudden profuse and persistent vomiting and by very +great prostration. All food, it may be even water, is promptly +rejected. The vomited matter is generally stained with bile; +occasionally the violence of the vomiting causes hæmatemesis. In many +cases the temperature is raised; sometimes it may be as high as 103° +F. The duration of an attack varies. In most cases it does not last +longer than forty-eight hours. On the other hand, attacks lasting as +long as a week are by no means unknown. Within a short time of the +onset the urine may be found to contain acetone bodies, the breath may +smell distinctly of acetone, and the child may become torpid and +drowsy or agitated and restless. At times there may be exaggerated and +deepened respiratory movements--the so-called air hunger. In many +cases, however, otherwise characteristic, these more severe +manifestations are absent or but little apparent. Recovery is usually +rapid and complete. The child asks for food, which is retained. A +fatal ending is very rare, though not unknown. The frequency of +attacks is very various. Sometimes months or even years may elapse +between successive seizures; in other cases a fortnightly or monthly +rhythm establishes itself. + +It is clear that both the frequency and the severity of the attacks +are much influenced by the general state of the child's health. Like +migraine, cyclic vomiting appears to be a symptom of nervous +exhaustion. It affects, for the most part, children who are +intellectually alert, impressionable, and forward for their age, and +who, when well, throw themselves into work or play with a great +expenditure of nervous energy. Often their physical development is +unsatisfactory, and we must set ourselves to correct this as the first +step in prevention. It is highly important that children suffering in +this way should have free opportunities for exercise in the open +country, and that all the excretory organs--the skin, kidneys, and +bowels--should be acting freely and efficiently. The child should live +a life of ordered routine. Sleep should be sound and sufficient in +amount. The diet must not exceed the strict physiological needs. Many +of these children appear to have a lowered tolerance for fats of all +sorts, and it may be necessary to limit strictly the consumption of +milk, cream, butter, and so forth. A daily administration of a small +dose of alkali by the mouth is credited with preventing attacks. In +the present connection, however, we shall not do wrong to emphasise +the part played by the nervous system in the production of the +attacks. In all cases of cyclic vomiting it should be our endeavour to +recognise and remove the elements in the daily life of the child which +are proving too exhausting. + +UNEXPLAINED PYREXIA + +In nervous children we sometimes meet with inexplicable rises of +temperature. The pyrexia may have the same periodic character as that +just noted in cases of cyclic vomiting. At intervals of three, four, +or five weeks there may be a rise of temperature to 103° F., or even +higher, which may last for two or three days before subsiding. In +other cases the chart shows a slight persistent rise over many weeks +or months. That in nervous children the temperature may be very +considerably elevated without our being able to detect much that is +amiss does not of course make it any the less necessary to be careful +to exclude organic disease. Pyelitis, tuberculosis, and latent otitis +media occur with nervous children as with others and must not be +overlooked. If, however, organic disease can be excluded, and if the +pyrexia is the only circumstance which prevents the decision that the +child is well and should be treated as well, then the thermometer may +be overruled and the pyrexia neglected. + + + + +CHAPTER VI + +ENURESIS + + +I have dealt in previous chapters with certain common disorders of +conduct in childhood, which show clearly their origin in the +apprehensions of the grown-up people who have charge of the children, +and in the unwise suggestions which they convey to them. The same +forces are at work in the production of enuresis, or bed wetting, +although the matter is here often complicated by the development later +on of a sense of shame and unhappiness in the child. There comes a +time when the child passionately desires to regain control and is +miserable about her failure, until the concentration of her thoughts +on the subject becomes a veritable obsession. Every night she goes to +bed with this only in her mind. Every night she falls asleep, +miserably aware that she will wake to find the bed wetted. The +suggestion impressed in the first place on the mind of the tiny child +by injudicious management has become fixed by the growing sense of +shame and the complete loss of self-confidence. + +It is usually taught that a great variety of causes is concerned in +producing enuresis. It is said to be due to a partial asphyxia during +sleep from adenoid vegetation. It is said to be caused by phimosis, +and to be cured by circumcision. It is said that the urine is often +too acid and so irritating that the bladder refuses to retain it for +the usual length of time. It is said that enuresis may be due to a +deficiency of the thyroid secretion, and that it can be cured by +thyroid extract. Such a number of rival causes may make us hesitate to +accept the claims of any one of them. Certainly I have not been able +to satisfy myself that any one of these conditions exercises any +influence at all or is commonly present in cases of enuresis. I think +that if we examine a large number of cases of bed wetting in children +we can come to no other conclusion than that the cause of the trouble +is due to just such a pervasion of suggestion as we have been +considering above. + +There are certain points in the behaviour of a child with enuresis +which seem to point to this conclusion. + +_(a)_ In the first place, the trouble is seldom serious or very well +developed in early childhood, and the reason for this, I take it, is +that an occasional lapse in a child of perhaps two or three years of +age is usually treated lightly and in the proper spirit of tolerance. +It is only with children a little older that nurses and parents become +distressed and begin unwittingly by urging the child to present the +suggestion to her mind, that the bed may or will be wetted. Hence the +usual history is that control was partially acquired in the second +year, but that, instead of later becoming complete, relapses began to +be more frequent, and that since that time all that can be done seems +only to make matters worse. + +_(b)_ In the second place, the influence of suggestion is shown by the +behaviour of the child when removed to a hospital for observation. It +is the invariable experience that the enuresis then promptly stops. In +hospital the attitude of those around the child is entirely different. +She has the comfortable and consoling feeling that in wetting the bed +she is doing exactly what is expected of her. There is even a feeling +that otherwise she is showing herself to be something of a fraud, and +that she has then been admitted to the hospital on false pretences. +Hence, perhaps for the first time in many years, the child is free +from the obsession, and the bed is not wetted. + +_(c)_ In the third place, it is easy to recognise in the history of +many of the cases, the ill-effects of circumstances which add new +force to the fear of failure or shake the confidence in the control +which had been regained. Thus a boy, an only child, who had suffered +from enuresis till his seventh year, had regained complete control +till his eleventh year, when he went to school. In his dormitory at +school was a boy who had enuresis, and who was being fined and +punished by the schoolmaster. The enuresis at once reappeared and +continued unchecked so long as he was at school. As might be expected, +school life is very inimical to cure, unless the trouble can be kept +from the knowledge of the other boys. Anything which directly +increases the nervousness of the child--an illness, for example, with +loss of weight and failure of nutrition, or some mental stress, such +as the approach of an examination--is apt to accentuate the enuresis. + +_(d)_ In the fourth place, the incontinence sometimes spreads to the +daytime, and the child is wet both by day and night. Further, in bad +cases it is not uncommon to find incontinence of fæces making its +appearance also. These extensions of the fault only take place when +the management continues to be very faulty, when the grown-up people +around them are more than usually distressed and pessimistic, and have +redoubled their expostulations and appeals. + +Now these peculiarities of enuresis seem to me only explicable if we +assume that the want of control is due to auto-suggestion, dependent +at the beginning on the unwise attitude adopted towards the fault by +the nurses and parents, and later kept up by the sense of shame and +the mental distress involved. + +The forms of treatment which have been recommended from time to time +are, as might be expected, very numerous. + +_(a) Operative._--(i) Removal of tonsils and adenoids, (ii) +Circumcision. + +_(b) Manipulative._--(i) Injection of saline solution under the skin +in the perineal and pubic regions, with object of lowering the +excitability of the bladder by counter-irritation. (ii) Gradual +distension of the bladder by hydrostatic pressure, (iii) Tilting the +foot of the bed so as to throw the urine to the fundus of the +bladder, in order to protect the sensitive trigone from irritation. + +_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the +child at intervals during the night by an alarm clock or otherwise. +(iii) Rewards and punishments. + +_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract. + +_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic +suggestion. + +I do not think that any single one of these various forms of treatment +outlined under the first four heads has any effect other than to aid +the suggestion of cure which we proffer in adopting it. Removal of +tonsils and adenoid vegetations might conceivably cure an enuresis +which is nocturnal, it cannot account for an incontinence which +spreads to the day. We might believe that to distend the bladder by +hydrostatic pressure was a cure for incontinence of urine, and that it +acted by removing the local cause,--the smallness and contraction of +the bladder,--were it not that the loss of control is so apt to spread +to the rectum as well. There is no evidence that the urine is +peculiarly irritating. Indeed, such evidence as we have goes to show +that, as in some other neuroses, the urine in enuresis is unduly +copious, and of very low specific gravity. Incidentally, we have in +this polyuria a further argument against the view recently advanced +that a small and contracted irritable bladder is the cause of +enuresis. We do, of course, meet with cases of irritable bladder often +enough, but the complaint is then not of incontinence, but always of +the discomfort of having to rise so frequently for micturition. + +To deprive the child of fluid, to wake her many times at night, to +tilt the foot of the bed, are devices which may help in the hands of +some one who is confident of his ability to cure the condition and can +communicate the confidence to the child. Carried out hopelessly and +pessimistically by a tired and exasperated mother, they are well +calculated to strengthen the hold which the obsession has on the +child, so that often we meet with a mother who rightly enough +maintains that the more she wakes the child, the oftener the bed is +wet, till she wonders where it all comes from. + +The treatment of enuresis to be successful must be conducted through +and by means of the grown-up persons who have the control of the +children. To stop the development of enuresis in early infancy we must +intervene to prevent the concentration of the child's mind on the +difficulty. During the time when control is ordinarily developed, in +the second and third year, judicious management of the child is +essential. The emphasis should be laid upon successes, not upon +failures. For every child his reputation will sway in the balance for +a time. He must be helped and encouraged to self-confidence, not +rendered diffident or self-conscious. + +If the case is well established before it comes under our notice, the +mother, the nurse, the schoolmaster, or whoever is responsible for the +child's management, must understand clearly the nature of the trouble. +The suggestion acting on the child's mind must be altered, and +self-confidence restored. The child must learn to see that the thing +is not so desperately tragic. He should be told that the trouble +always gets well, and that it only goes on now because he is worried +about it and keeps thinking of it. If the whole environment of the +child is bad, so that such a change of suggestion is not possible, and +if enuresis is but one of many symptoms of mental or moral +instability, it may be necessary to remove the child and place him +under the influence of some one else. Sometimes the prescription of a +rubber urinal, which the child can slip on at night, is directly +curative. A public school boy, who was about to be sent away from +school for this failing, fortified by the possession of this +apparatus, wrote six months later to say that he knew now that it must +be all worry that caused the trouble, because with the urinal in +position he had not once had the incontinence. + +In inveterate cases hypnotic suggestion is always, I think, +successful. It is obvious, however, that in many cases there are +objections to its use. Often enuresis is evidence that the child's +home environment has been at fault, and that his mental and moral +development has been retarded. It is the management which must be +modified or the home, if necessary, changed. Hypnotic suggestion will +make this one symptom disappear promptly enough, but it will rather +perpetuate than combat the cause--that undue susceptibility to +suggestion, which is characteristic alike of the little child and of +many older neuropathic persons. + + + + +CHAPTER VII + +TOYS, BOOKS, AND AMUSEMENTS + + +Any one who has an opportunity of watching little children must have +observed that they are happiest and most contented when playing alone. +The education of the little child is carried on by means of games and +toys. Handling the various objects which we give him, imparting +movement to them, transferring them from hand to hand and from one +situation to another, he learns dexterity and precision of movement, +and in the process hand and brain grow in power. When at play, his +whole energies should be absorbed to the exclusion of everything else. +He will often be oblivious to everything that is going on around him, +intent only on the purpose of the moment. In order to permit this +fervour of self-education it is necessary that the child should be +accustomed to playing alone, and it is well, if only for convenience' +sake, that he should be accustomed to playing in a room by himself. +Something is wrong if the child cannot be left for a few moments +without breaking into tears or displaying bad temper. Engrossed in his +own tasks, he should be content to leave his nurse to move in and out +of the room without protest. If this fault has appeared and the child +cannot be left alone, our whole educational system is undermined, and +play will be profitless and over-exciting, because it demands the +constant participation of grown-up people. As a preliminary to all +improvement in the management of a nervous child, we must see to it +that he becomes accustomed to being alone. We must so arrange his +nursery that he can do no damage to himself. Scissors and matches must +not be left lying about, and a fireguard must be fixed in position so +that it cannot be disturbed. Then, disregarding his protests, the +nurse must leave him to himself, at first only for a moment or two, +re-entering the room in a matter-of-fact way without speaking to him, +and again leaving it. Soon he will learn that a temporary separation +does not mean that we have abandoned him for all time. Then the period +of absence can be gradually lengthened till all difficulty disappears. +Once his attention is removed from the grown-up people who mean so +much to him, his natural impulse to explore and experiment with his +playthings will show itself. Those toys are best which are neither +elaborate nor expensive. For a little child a small box containing a +miscellaneous collection of wooden or metal objects, none of them +small enough to be in danger of being swallowed, forms the material +for which his soul craves. Everything else in the room may be out of +his reach. A dozen times he will empty the box and then replace each +object in turn. He will arrange them in every possible combination, +and then sweep the whole away to start afresh. + +At eighteen months of age observation and imitative capacity will +have made more complex pursuits possible. As a rule the objects which +are most prized and which have most educative value are those which +lend themselves best to the actions with which alone the child is +familiar. Hence the supreme importance of the doll and the doll's +perambulator. The doll will be treated exactly as the child is treated +by the nurse. It will be washed, and dressed, and weighed, and put to +bed in faithful reproduction of what the child has daily experienced. +Dusting, and sweeping, and laying the table will be exactly copied. If +a child has no opportunity of being familiar with horses, if he has +not seen them fed, and watered, and groomed, and harnessed, he may not +find any great satisfaction in a toy horse, or pay much attention to +it, no matter how costly or realistic it may be. + +In the third year more precise tasks, such as stringing beads, +drawing, and painting, will play their part, while at the same time +the increased imaginative powers will give attraction to toy soldiers +or a toy tea-service. Playing at shop, robbers, and rafts are +developments of still later growth. In the child's games we recognise +the instinct of imitation--playing with dolls, sweeping and dusting, +playing at shop or visitors; the instinct of constructiveness--making +mud pies and sand castles, drawing or whittling a stick; and the +instinct of experiment--letting objects fall, rattling, hammering, +taking to pieces. All this activity must be encouraged, never unduly +repressed or destroyed. But whatever form it takes, the bulk of the +play must be carried on without the intervention of grown-up persons, +or it will lose its educative value and prove too exacting. If +grown-up people attempt to take part, the child will lose interest in +the play and turn his attention to them. + +Children differ very much in their attitude towards books. One child +quite early in the second year will be happy poring over picture +books, while another will seldom glance at the contents and finds +pleasure only in turning over the pages, opening and shutting them, +and carrying them from place to place. Such differences are natural +enough and foreshadow perhaps the permanent characteristics that +divide men and women, and produce in later life men of thought and men +of action, women who are Marthas and women who are Marys. +Nevertheless, we should bear in mind that there is danger in a +training that is too one sided, and that books and toys have both +their part to play in developing the powers of the child. All the +activities of the child should be used in as varied a way as possible. +The eye is but one doorway to knowledge and understanding, the ear is +another, the hand a third. + +From pictures an imaginative child will derive very strong +impressions, and mothers should be careful in their choice. It is +foolish to confuse the growth of æsthetic perceptions by presenting +children with books which depict children as grotesquely ugly beings +with goggle eyes and heads like rubber balls. Children love animals +and endow them with all their own reasoning attributes, and in +stories of the home life of rabbits, and bears, and squirrels they +take a pure delight. Books of the "Struwwelpeter" type are less to be +recommended. The faults which they are intended to eradicate become +peculiarly attractive from much familiarity. A little boy of two and a +half who resolutely refused all food for some days was in the end +detected to be playing the part of that Augustus, once so chubby and +fat, who reduced himself to a skeleton, saying, "Take the nasty soup +away; I don't want any soup to-day." Tales of naughty children who +meet with a distressing fate may either frighten the child unduly, or +else produce in a child of inquiring mind the desire to brave his fate +and put the matter to the test. Pictures should not be terrifying or +horrible. Ogres devouring children are out of place as subjects for +pictures and may cause night-terrors. + +Children should be taught to be careful of books and toys. The +indestructible book, generally falsely so called, is often responsible +for the immediate dissolution of all others less protected which come +to hand. The sympathy which little children have with the sufferings +of all inanimate objects and their habit of endowing them with their +own sensations may be made of use in teaching them care and +gentleness. They are naturally prone to sympathise with the doll that +has been crushed or the book that has been torn. They will learn very +easily to be kind to a pet animal and to be solicitous for its +feelings, and the lesson so learnt will be applied to inanimate +objects as well. + +There is, however, another side to the question. It is true that if +the child is not to be over-stimulated upon the psychical side, we +must see to it that his play, for the most part, is not dependent upon +the participation of grown-up persons. In practice this excessive +stimulation is the common fault with which we meet. There are few +children in well-to-do homes, with loving mothers and devoted nurses, +who suffer from too little mothering and nursing. Too many show signs +of too much. To observe the opposite fault we must seek the infants +and children who for a long time are inmates of institutions, +orphanages, infirmaries, hospitals, and so forth. In such surroundings +the mental life of the child may languish. His physical wants are +cared for, but there the matter ends. In a rigid routine he is washed +and fed, but he may not be talked to or played with or stimulated in +any way. His day is spent passively lying in his cot, unnoticed and +unnoticing. I have seen a poor child of three years just released from +such a life, and after eighteen months returned to his mother, unable +to talk and almost unable to walk, crying pitifully at the novelty and +strangeness of the noisy life to which he had returned, worried by +contact with the other children, and without any desire or power to +occupy himself in the home. For an hour in the day mothers may devote +themselves wholeheartedly to the children, and if they set them +romping till they are tired out, so much the better. In the garden or +in an airy room with the windows open, a game with a ball or a toy +balloon, or a game of hide-and-seek, will be all to the good, and the +children may climb and be rolled over and swung about to their heart's +content. With an only child, especially with a child whose home is in +town, and whose outings are limited to a sedate airing in the park, +such free play is especially necessary. It may help more than anything +else to quiet restless minds and tempers that are on edge all day long +from excessive repression. + +On the other hand, those forms of entertainment which are known as +"children's parties" are generally fruitful of ill results, at any +rate with nervous and highly-strung children. Sometimes they entail a +postponement of the usual bedtime, and nearly always they involve +over-heated and crowded rooms. Perverse custom has decreed that these +gatherings shall take place most commonly in the winter, when dark and +cold add nothing to the pleasure and a great deal to the risk of +infection which must always attend the crowding of susceptible +children together in a confined space with faulty ventilation. There +is clearly on the score of health much less objection to summer garden +parties for children, but these for some reason are less the vogue. As +a rule parties are not enjoyed by nervous children. There is intense +excitement in anticipation, and when at length the moment arrives, +there is apt to be disillusion. Either the excitement of the child may +pass all bounds and end in tears and so-called naughtiness, or the +unfamiliar surroundings may leave him distrait with a strange sense of +unreality and unhappiness. It is not always fair to blame the want of +wisdom in his hostess's choice of eatables, if the excited and +overstimulated child fails in the work of digestion and returns to the +nursery to suffer the reaction, with pains and much sickness. + +The same arguments may be urged against taking little children to the +theatre. The nerve strain is apt to be out of proportion to the +enjoyment gained. If children must go to theatres and parties, the +treat should be kept secret from them until the moment of its +realisation, in order that the period of mental excitement should be +contracted as much as possible, and grown-up people should be advised +to treat the whole expedition in a matter-of-fact sort of way that +does nothing to add to the excitement or increase the risk of +subsequent disillusion. + + + + +CHAPTER VIII + +NERVOUSNESS IN EARLY INFANCY + + +We may now pass back to consider the nervous system of the child in +infancy. There, too, from the moment of birth there are clearly-marked +differences between individuals. The newborn baby has a personality of +his own, and mothers will note with astonishment and delight how +strongly marked variations in conduct and behaviour may be from the +first. One baby is pleased and contented, another is fidgety, +restless, and enterprising. At birth the baby wakes from his long +sleep to find his environment completely changed. Within the uterus he +lies in unconsciousness because no ordinary stimulus from the outer +world can reach him to exert its effect. He lies immersed in fluid, +which, obeying the laws of physics, exercises a pressure which is +uniformly distributed over all points of his body. No sound reaches +him, and no light. After birth all this is suddenly changed. The sense +of new points of pressure breaks in upon his consciousness. Cold air +strikes upon his skin. Loud sounds and bright lights evoke a +characteristic response. A placid child who inherits a relatively +obtuse nervous organisation will be but little upset by this sudden +and radical change in the nature of his environment. His brain is +readily but healthily tired by the new sensations which stream in from +all sides, and he falls straight away into a sleep from which he +rouses himself at intervals only under the impulse of the new +sensation of hunger. + +Babies of nervous inheritance, on the other hand, will show clearly by +the violence of the response provoked that their nervous system is +easily stimulated and exhausted. They will wriggle and squirm for +hours together, emitting the same constant reflex cry. The whole body +will start convulsively at a sudden touch or a loud sound which would +evoke no response from a more stolid infant. The sleeplessness and +crying exhaust the baby, rendering the nervous system more and more +irritable, while the sensation of hunger which is delayed in other +children by twelve hours or more of deep sleep appears early and is of +extreme intensity. We must see to it that sense stimuli are reduced to +the lowest possible level. True, we cannot again restore the child to +a bath of warm fluid, of the same temperature as his body, where he +can be free from irksome pressure and from all sensations of sound and +light, but we can so arrange matters that he is not disturbed by loud +sounds and bright lights, and that he is not moved more than is +necessary. Sudden unexpected movements are especially harmful. Jogging +him up and down, patting him on the back, expostulation, and +entreaties are all out of place and do all the harm in the world. The +first bath should be as expeditious as possible, and above all the +baby must not be chilled by tedious exposure. Cold irritates his +nervous system more than anything else, unless it be excessive warmth. +In preserving the proper temperature so that we do not render the +child restless by excess of heat or by excess of cold, we +too-civilised people have made our own difficulties. We have +exaggerated the completeness of the sudden separation of mother and +child which nature decrees. It is the function of all mother animals +to approximate the unstable temperature of the newly born to their own +by the close contact of their bodies, which provide just the proper +heat. Labour is nowadays so complicated and exhausting a process for +mothers that, all things considered, we are wise in completing the +separation of mother and child and in removing the baby to his own +cot. But the difficulty remains, and we must arrange that any +artificial heating needed is constant and of proper degree. + +If the baby is very restless and irritable, too wide awake and too +conscious of his surroundings, the all-important task of getting him +to the breast and getting him to draw the milk into the breast is apt +to be difficult. His sucking is a purely reflex and involuntary act. +It can be produced by anything which gently presses down the tongue, +and a finger placed in the proper position will provoke the movement +without the child's consciousness being aroused. The placid child +whose mind is at rest will suck well and strongly. If, on the other +hand, the brain is too much stimulated and the child is restless and +irritable, the reflex act of suction is inhibited, and it is a +difficult matter to get the child to the breast. He is too eager, +mouthing, and gulping, and spluttering. Or sometimes his mental +sufferings seem too much for his appetite, and though wide awake and +crying loudly, he refuses to grasp the nipple, turning his head away +and wriggling blindly hither and thither. This effect of mental unrest +on the newborn infant is often disastrous, because it is one of the +common causes of the failure of women to nurse their children. This is +not the place to sketch in detail a scheme for the proper technique of +breast nursing, a matter which is much misunderstood at the present +day. It will be enough shortly to say that an efficient supply of milk +depends upon the complete and regular emptying of the breast. The +breasts of all mothers will secrete milk if strong and vigorous +suction is applied to the nipple by the child. If anything interferes +with suction, the milk does not appear or, if it has appeared, it +rapidly declines in amount. The mother's part is to a great extent a +passive one, provided that she can supply one essential--a nipple that +is large enough for the child to grasp properly. Within wide limits +what the mother eats or drinks, whether she be robust or whether she +has always been something of an invalid, matters not at all. A frail +woman may naturally not be able to stand the strain of nursing for +many months, but that is not here the point in question. We are +dealing only with the establishment of lactation and with the milk +supply of the early days and weeks which is of such vital importance +for the child. If the mother is ill, if, for example, she has +consumption, we may separate her from the child in the interests of +both; but if this is not done, she will continue to secrete milk for a +time as readily as if she were in perfect health, and the breasts of +many a dying woman are to be seen full of milk. Mothers are too apt to +attribute the disappointment of a complete failure to nurse to some +weakness or want of robustness in their own health. This is never the +reason of the failure, and the fault, if the mother has a well-formed +nipple, is generally to be found in some disturbance in the child. +Prematurity, with extreme somnolence, breathlessness from respiratory +disease, nasal catarrh, which hinders breathing through the nose, +infections of all sorts, are common causes of this failure to suck +effectively. But perhaps the most common cause of all is the +inhibition from nervous unrest of that reflex act of sucking which +works so well in the placid and quiet child. It is a point to which +too little attention is paid, and mothers and the books which mothers +read commonly neglect the nervous system of the child and devote +themselves to such considerations as the relative merits of two-hourly +and four-hourly feedings--important points in their way, but less +important than this. + +The matter is complicated in two other ways. In the first place, the +nervous baby, just because he is so active and wakeful and restless, +is apt rapidly to lose weight and to have an increased need for food. +The restlessness is generally attributed to hunger, and this is true, +because hunger is soon added to the other sensations from which he +suffers, and like them is unduly acute. It is difficult not to give +way and to provide artificial food from the bottle. Yet if we do so we +must face the fact that these restless little mortals are quicker to +form habits than most, and once they have tasted a bottle that flows +easily without hard suction, they will often obstinately refuse the +ungrateful task of sucking at a breast which has not yet begun to +secrete readily. The suction that is devoted to the bottle is removed +from the breast, and the natural delay in the coming in of the milk is +increased indefinitely. At the worst, the supply of milk fails almost +at its first appearance. We must devote our attention to quieting the +nervous unrest by removing all unnecessary sensory stimulation from +the baby. He must be in a warm cot, in a warm, well-aired, darkened, +and silent room, and the necessary handling must be reduced to a +minimum. Sometimes sound sleep will come for the first time if he is +placed gently in his mother's bed, close to her warm body. If he is +apt to bungle at the breast from eagerness and restlessness, it is not +wise always to choose the moment when he has roused himself into a +passion of crying to attempt the difficult task. So far as is possible +he should be carried to the breast when he is drowsy and sleepy, not +when he is crying furiously, and then the reflex sucking act may +proceed undisturbed. + +In the second place, we must guard against the ill effect which the +ceaseless crying of these nervous babies has upon the mother. She may +be so exhausted by the labour that her nerves are all on edge, and she +grows apprehensive and frightened over all manner of little things. +The tired mother is apt to fear that she will have no milk, and her +agitation grows with each failure on the part of the child. Now the +first secretion of milk is very closely dependent upon the nervous +system of the mother. We have said that within wide limits her +physical condition is of less importance, but her peace of mind is +essential. And so it is wise for some part of the day to keep the +nervous baby out of hearing of the mother, and so far as possible to +choose moments when the child is quiet to put him to the breast. A +nurse with a confident, hopeful manner will effect most; a fussy, +over-anxious, or despondent attitude will do untold harm. We shall +sometimes fail if the nervous unrest is very obstinate either in +mother or in child, but we shall fail less often if we diagnose the +cause correctly in the cases we are considering. Lastly, it is +possible to control the condition in both mother and child by the +careful use of bromide or chloral. + +It is not, of course, suggested that these drugs should be given +freely or as a routine to every hungry baby wailing for the breast, or +that we can hope to combat or ward off an inherited neuropathy by a +few doses of a sedative. There are, however, not a few babies in whom +there develops soon after birth a sort of vicious circle. They can +suck efficiently and digest without pain only when they sleep soundly. +If they are put to the breast after much crying and restlessness, +each meal is followed by flatulence, colic, and renewed crying. The +only effective treatment is to secure sleep and to carry a slumbering +or drowsy infant to the breast. Then the sucking reflex comes to its +own again, the breast is drained steadily and well, and digestion +proceeds thereafter without disturbance and during a further spell of +sleep. Two or three times in the day we may be forced, as meal-time +approaches, to cut short the restlessness of the child by giving a +teaspoonful of the following mixture: + +Pot. brom., grs. ii. [2 grains] + +Chloral hydrate, gr. i. [1 grain] + +Syrup, M x. [10 minims] + +Aq. menth. pip., ad 3 i. [1 dram] + +After this has been taken the child should be laid down for a quarter +of an hour until soundly asleep. Then very gently he can be carried to +his mother and the nipple inserted. If in this way a few days of sound +sleep and less disturbed digestion can be secured, the difficulty will +in most cases permanently be overcome. The steadier suction and more +efficient emptying of the breast will promote a freer flow of milk, +and the deeper and more prolonged sleep will lower greatly the needs +of the child for food. Most of the babies who show this fault are +thin, meagre, and fidgety, and with some increase of muscular tone. +The head is held up well, the limbs are stiff, the hands clenched, the +abdomen retracted, with the outline of the recti muscles unusually +prominent. If we can relax this exaggerated state of nervous tension, +if we can help them to become fatter and to put on weight, the +dyspepsia will disappear with the other symptoms. + +It is a question still to be answered whether the rare conditions of +pyloric spasm and pyloric hypertrophic stenosis are not further +developments of the same disturbance. Certainly these grave +complications appear most commonly in infants with a pronounced +nervous inheritance, and, as might be expected, they are more commonly +found in private practice than among the hospital classes. + +In passing, we may note that there are babies who exhibit the opposite +fault, and in whom the contrary regimen must be instituted. Premature +children, children born in a very poor state of nutrition, and +children born with great difficulty, so that they are exhausted by the +violence of their passage into the world, are apt to show the opposite +fault of extreme somnolence. They are so little stimulated by their +surroundings, and they sleep so profoundly, that the sucking reflex is +not aroused. Put to the breast they continue to slumber, or after a +few half-hearted sucking movements relapse into sleep. We must rouse +such children by moving them about and stirring them to wakefulness +before we put them to the breast. + +Once the child has been got to the breast, once the milk has become +firmly established, we have overcome the first great difficulty which +besets us in the management of nervous little babies, but it is by no +means the last. Restlessness and continual crying must be combated or +digestion suffers, and may show itself in a peculiar form of explosive +vomiting, which betokens the reflex excitability and unrest of the +stomach. + +The sense of taste is as acute as all other sensations. If the child +is bottle-fed, the slightest change in diet is resented because of the +unfamiliar taste, and the whole may promptly be rejected. The tendency +to dyspeptic symptoms is apt to lead to much unwise changing of the +diet, and everything tried falls in turn into disrepute, until perhaps +all rational diets are abandoned, and some mixture of very faulty +construction, because of its temporary or accidental success, becomes +permanently adopted--a mixture perhaps so deficient in some necessary +constituent that, if it is persisted with, permanent damage to the +growth of the child results. We must pay less attention to changes of +diet and explore our management of the child to try and find how we +can make his environment more restful. + +It is wise to accustom a nervous child from a very early age to take a +little water or fruit juice from a spoon every day. Otherwise when +breast-feeding or bottle-feeding is abandoned one may meet with the +most formidable resistance. Infants of a few months can be easily +taught; the resistance of a child of nine months or a year may be +difficult to overcome. The difficulty of weaning from the breast +recurs with great constancy in nervous children. By this time the +influence of environment has become clearly apparent. The child is +often enough already master of the situation, and is conscious of his +power. Such children will sometimes prefer to starve for days +together, obstinately opposing all attempts to get them to drink from +a spoon, a cup, or even a bottle. When this happens, sometimes the +only effective way is to change the environment and to send the baby +to a grandmother or an aunt, where in new surroundings and with new +attendants the resistance which was so strong at home may completely +disappear. When weaning is resented, and difficulties of this sort +arise, it is clear that the mother, whose breast is close at hand, is +at a great disadvantage in combating the child's opposition. + +For nervous infants, alas! broken sleep is the rule. What, then, is to +be done? It is astonishing to me that any one who has studied the +behaviour of only a few of these nervous and restless infants should +uphold the teaching that the crying of the young infant is a bad +habit, and that the mother who is truly wise must neglect the cry and +leave him to learn the uselessness of his appeals. It is true that the +youngest child readily contracts habits good or bad. Either he will +learn the habit of sleep or the habit of crying. Mercifully the +inclination of the majority is towards sleep. But to encourage habits +of restlessness and crying there is no surer way than to follow this +bad advice and to permit the child to cry till he is utterly exhausted +in body and in mind. It is unwise _always_ to rock a baby to sleep; it +is also unwise to allow him to scream himself into a state of +hysteria. A quiet, darkened room, the steady pressure of the mother's +hand in some rhythmical movement, will often quiet an incipient +storm. The longer he cries, the more trouble it is to soothe him. +Sleep provokes sleep, so that often we find restlessness and sound +sleep alternating in a sort of cycle, a good week perhaps following a +bad one. The nurse who is quick to cut short a storm of crying and to +soothe the child again to sleep is helping him to form habits of +sleep. The nurse who leaves him to cry, believing that in time he will +of his own accord recognise the futility of his behaviour, is making +him form habits of crying. A rigid routine in sleep is a good thing, +but the routine belongs to the baby, not to the nurse. The child must +be educated to sleep, not taught to cry. A baby has but little power +of altering his position when it becomes strained or uncomfortable. He +cannot turn over and nestle down into a new posture. If we watch him +wake, the first stirring may be very gradual, and in a moment he may +fall again to sleep. A few minutes later he stirs again more strongly, +and is wider awake and for longer. It may only be after a third +waking, by a summation of stimuli, that he is finally roused and +breaks into loud crying. The nurse who is on the watch, who, sleeping +beside him, wakes at the slightest sound and is quick to turn him over +and settle him into a new position of rest, will probably report in +the morning that the baby has had a good night. The nurse who lets the +child grow wide awake and start crying loudly, will spend perhaps many +hours before quiet is again restored. Of the voluntary, purposive +crying of infants a little older I am not here speaking. Infants in +the second six months are quite capable of establishing a "Tyranny of +Tears" and feeling their power. Fortunately it requires no great +experience to distinguish one from the other, and to adopt for each +the appropriate treatment. + +Again, in elementary teaching upon the management of infants stress is +laid, rightly enough, upon the importance of regularity in the times +of feeding, and on the observance in this respect also of a very +strict routine. But in the case of the very nervous infant a certain +latitude should be allowed to an experienced nurse or mother. We may +wreck everything by a blind adhesion to a too rigid scheme, which may +demand that we leave the child to scream for an hour before his meal, +or that, when at length he has fallen into a sound sleep after hours +of wakefulness, we should proceed to wake him. + +Symptoms of dyspepsia which are due to continued nervous excitement +demand treatment which is very different from that which would be +appropriate to dyspepsia which is due to other causes, such as +overfeeding or unsuitable feeding. The temporary restriction of food, +which is commonly ordered in dyspepsia from these causes, is very +badly supported by the nervous infant. Hunger invariably increases the +unrest, and the unrest increases the dyspepsia. + +The difficulties of managing a nervous infant are very real, and call +for the most exemplary patience on the part of the mother and the +clearest insight into the nature of the disturbance. + + + + +CHAPTER IX + +MANAGEMENT IN LATER CHILDHOOD + + +In the early days in the nursery the actions of the infant, for the +most part, follow passively the traction exercised by nurses and +mothers, sometimes consciously, but more often unconsciously. We have +now to consider a period when the child becomes possessed of a driving +force of his own, and moves in this direction or that of his own +volition. In this new intellectual movement through life he will not +avoid tumbles. He will feel the restraints of his environment pressing +upon him on all sides, and he will often come violently in contact +with rigid rules and conventions to which he must learn to yield. From +time to time we read in the papers of some terrible accident in a +picture-palace, or in a theatre. Although there has been no fire, +there has been a cry of fire, and in the panic which ensues lives are +lost from the crowding and crushing. Yet all the time the doors have +stood wide open, and through them an orderly exit might have been +conducted had reason not given place to unreason. It is the task of +those responsible for the children's education to guide them without +wild struggling along the paths of well-regulated conduct towards the +desired goal, influenced not by the emotions of the moment, but only +by reason and a sense of right; not ignorant of the difficulties to be +met, but practised and equipped to overcome them. + +It is easy thus to state in general terms the objects of education, +and the need for discipline. To apply these principles to the +individual is a task, the immeasurable difficulty of which we are only +beginning to appreciate with the failure of thirty years of compulsory +education before us. A recent writer[2] gives it as his opinion that +the aim of education is to equip a child with ideals, and that this +task should not be difficult, because the lower savages successfully +subject all the members of their tribe to the most ruthless +discipline. Their lives, he says, "are lived in fear, in restraint, in +submission, in suffering, subject to galling, unreasoning, +unnecessary, arbitrary prohibitions and taboos, and to customary +duties equally galling, unreasoning, unnecessary, and arbitrary. They +endure painful mutilations, they submit to painful sacrifices.... How +are these wild, unstable, wayward, impulsive, passionate natures +brought to submit to such a rigorous and cruel discipline? By +education; by the inculcation from infancy of these ideals. In these +ideals they have been brought up, and to them they cling with the +utmost tenacity." One might as well contend that it was easy to teach +all men to live the self-denying life of earnest Christians because +some savage tribe was successful in maintaining among its members a +universal and orthodox worship of idols. The ideals set before the +child are too high and too complex to be inculcated by physical force, +or even by force of public opinion. A rigid discipline, with many +stripes and with terrible threats of a still worse punishment in the +world to come, was the almost invariable lot of children until the +last century was well advanced. Yet has this drastic treatment of +young children fulfilled its purpose? Were the men of fifty years ago +better conducted and more controlled than the men of to-day? In any +one family did a greater proportion turn out well? Is it not true that +at least among the educated classes the relaxation of nursery and +schoolroom discipline which the last fifty years has seen has been +justified by its results? Is it not true that the childhood of our +grandmothers was often lived "in fear, in restraint, in submission, in +suffering subject to galling, unreasoning, unnecessary, arbitrary +prohibitions and taboos, and to customary duties equally galling, +unreasoning, unnecessary, and arbitrary." And though perhaps the +grandmothers of most of us may not have been much the worse for all +this discipline, is it not true that of the little brothers who shared +the nursery with them a surprising number broke straightway into +dissipation when the parental restraints were removed? If we are to +teach a child to be gentle to the weak it is not wise to beat him. The +qualities which we wish him to possess are not more subtle than the +means by which we must aid him to their possession. + +[Footnote 2: _The Principles of Rational Education_, by Dr. C.A. +Mercier.] + +Education comprises physical, mental, and moral training. In earlier +times physical strength and the power to fight well, alone were prized +and were the chief objects to be gained in the education of youth. +Later, under the stress of intellectual competition for success in +life, mental acquirements have come to occupy the first place. We are +only now learning to lay emphasis upon the supreme need for moral +training. Not that it is possible to separate the sum of education +into its constituent parts, and to regard each as distinct from the +others. That many men of great intellectual activity, and many men +pre-eminent for their moral qualities have harboured a great brain or +a noble character in a weakly or deformed body, forms no argument to +disprove the general rule that a healthy, vigorous physique is the +only sure foundation upon which to build a highly developed intellect +and a stable temperament. In childhood the intimate connection between +vigour of mind and vigour of body is almost always clearly shown. A +child with rickets, unable to exercise his body in free play, as a +rule shows a flabbiness of mind in keeping with his useless muscles +and yielding bones. Such children talk late, are infantile in their +habits and ways of thought, and are more emotional and unstable than +healthy children of the same age. The connection between bodily +ailments and instability of nervous control is even more clearly seen +in the frequent combination of rheumatism and chorea. A very high +proportion of older children suffering from the graver neuroses, such +as chorea, syncopal attacks, phobias, tics, and so forth, show +defective physical development. Scoliosis, lordosis, knock-knee, flat +foot, pigeon chest, albuminuria, cold and cyanosed extremities, are +the rule rather than the exception. If the body of the child is +developed to the greatest perfection of which it is capable we shall +not often find a too sensitive nervous system. The boy of fine +physique may have many faults. He may be bad-tempered or untruthful or +selfish, but such faults as he has are as a rule more primitive in +type, more readily traced to their causes, and more easy to eradicate +than the faults which spring from that timidity, instability, and +moral flabbiness which has so often developed in the lax delicate +child reared softly in mind and body. + + +PHYSICAL TRAINING + +Children thrive best in the healthy open-air life of the country, and +if there is any tendency to nervous disturbances the need for this +becomes insistent. Physical training, further, includes the manual +education of the child. The system of child-training advocated by Dr. +Montessori is based upon the cultivation of tactile sensations and the +development of manual dexterity. Exercises such as she has devised +have an immediate effect in calming the nervous system and in changing +the restless or irritable child into a self-restrained and eager +worker. Lord Macaulay, whose phenomenal memory as a child has become +proverbial, was so extraordinarily unhandy that throughout life he had +considerable difficulty in putting on his gloves, while he had such +trouble with shaving that on his return from India there were found in +his luggage some fifty razors, none of which retained any edge, and +nearly as many strops which had been cut to pieces in his irritated +and ineffectual efforts. If we teach a child manual dexterity it is an +advantage to him, because manual dexterity is seldom associated with +restlessness and irritability of mind. To excel in some handicraft not +only bespeaks the possession of self-control, it helps directly to +cultivate it. The teaching of Froebel and Montessori holds good after +nursery days are over. + + +MENTAL TRAINING + +Mental training enables the child to retain facts in his memory, to +obtain information from as many sources as possible, to understand and +piece them together, and finally to reach fresh conclusions from +previously acquired data. So far as is possible the teacher must +satisfy the natural desire to know the reason of things. It must be +his endeavour to prevent the child from accepting any argument which +he has not fully understood, and which, as a result, he is able not to +reconstruct but only to repeat. Mental work which is slovenly and +perfunctory is as harmful to the child's education as mechanical work +which is bungled and ineffective. Taking advantage of his natural +aptitudes, his interest should be developed and extended in every way +possible. Tasks which are accomplished without enthusiasm are labour +expended in vain, because the knowledge so acquired is not +assimilated and adds nothing to the child's mental growth. There +should be no sharp differentiation between work and play. + + +MORAL TRAINING + +Moral training depends upon the force of example rather than of +precept. Parents must be scrupulously just and truthful to the child, +for his quick perception will detect the slightest deceit, and the +evil impression made on his mind may be lasting. They must confidently +expect conduct from him of a high moral standard, and be careful at +this early age to avoid the common fault of giving a dog a bad name. +If it is said on all sides that a child has an uncontrollable temper, +is an inveterate grumbler, is lacking in all power of concentration, +or has a tendency to deceit, it is likely that the child will act up +to his reputation. He comes in time to regard this failing of his as +part of himself just as much as is the colour of his hair or the +length of his legs. It may be said of a schoolboy that he shows no +aptitude for his work. Term by term the same report is brought home +from school, and each serves only to confirm the boy in his belief +that this failing is part of his nature, and that no effort of his own +can correct it. If one subject only has escaped the condemnation of +his master, then it may be to that study alone that he returns with +zest and enjoyment. Spendthrift sons are manufactured by those fathers +who many times a day proclaim that the boy has no notion of the value +of money. + +And so with children! Parents must take it for granted that they will +display all the virtues they desire in them. They must trust to their +honour always to speak the truth, and always to do their best in work +or play whether they are with them or not. Again and again the +children will fail and their patience will be tried to the utmost. +They must explain how serious is the fault, and for the time being +their trust may have to be removed; but with the promise of amendment +it must again be fully restored and the lapse completely forgotten. If +the child feels he is not trusted he ceases to make any effort, and +lapse will succeed lapse with increasing frequency. + +In efforts at moral training there is often too great an emphasis laid +upon negative virtues. It is wrong to do this: to do that is +forbidden. Children cannot progress by merely avoiding faults any more +than a man may claim to be an agreeable companion at table because he +does not eat peas with a knife or drink with his mouth full. There +must be a constant effort to achieve some positive good, to acquire +knowledge, to do service, to take thought for others, to discipline +self, and the parent will get the best result who is comparatively +blind to failure but quick to encourage effort and to appreciate +success. When the child knows well that he is doing wrong, exhortation +and expostulation are usually of little avail if repeated too often, +and serious talks should only take place at long intervals. + +We know how effective the so-called "therapeutic conversation" may be +in helping some overwrought and nervously exhausted man or woman to +regain peace of mind and self-control. After an intimate conversation +with a medical man who knows how to draw from the patient a free +expression of the doubts, anxieties, and fears which are obsessing +him, many a patient feels as though he had awakened in that instant +from a nightmare, and passes from the consulting-room to find his +troubles become of little account. Not a few patients return to be +reassured once more, and derive new strength on each occasion. Yet +visits such as these must be infrequent or they will lose their power. +Now, just as the physician is well aware that his intervention if too +frequently repeated will lose its effect, so the parent must be chary +of too frequent an appeal to the moral sense of the child. At long +intervals opportunity may be taken with all seriousness to set before +the child ideals of conduct, to-speak to him of the meaning of +character and of self-discipline, and of the standards by which we +judge a man or woman to be weak and despicable, or strong and to be +admired. The effect of such an intimate conversation, never repeated, +may persist throughout life. Constantly reiterated appeals, on the +other hand, do more harm than good. To tell a child daily that he is +"breaking mother's heart," or that he is "disappointing his father," +is to debase the moral appeal and deprive it of its strength. + +For everyday use it is best to cultivate a manner which can indicate +to the child that he is for the moment unpopular, but which at the +same time denies to the small sinner the interest of attempting his +own defence. On the other hand, should the child be reasonably in +doubt as to the nature of his offence we must spare no trouble in +explaining it to him. Punishment will be most effective when the child +is convinced that he is rightly convicted. If it is to act as a real +deterrent, he must agree to be punished--a frame of mind which, if it +can be produced, may be welcomed as a sure sign that training is +proceeding along the right lines. + +By physical training, mental training, and moral training the child's +character is formed and self-discipline is developed. With the child +of neuropathic disposition and inheritance matters may not proceed so +smoothly. Reasoning and conduct may be alike faulty, and the nervous +disturbances may even cause detriment to the physical health. Not that +the nervous child requires an environment different from that of the +normal child. The difficulties which the parents will encounter and +the problems which must be solved differ not in kind but in degree. An +error of environment which is without effect in the normal child may +be sufficient to produce disastrous results in the neuropathic. + +It must be granted that there are some unfortunate children in whom +the moral sense remains absent and cannot be developed--children who +steal and lie, who seem destitute of natural affection, or who appear +to delight in acts of cruelty. These moral degenerates need not be +considered here. Serious errors of conduct, however, in children who +are not degenerate or imbecile, frequently arise directly from faults +of management and can be controlled by correcting these faults. +Suppose, for example, that a child is found to have taken money not +his own. The action of the parents faced with this difficulty and +disappointment will determine to a great extent whether the incident +is productive of permanent damage to the child's character. The +peculiar circumstances of each case must be considered. For example, +the parent must bear in mind the relation in which children stand to +all property. The child possesses nothing of his own; everything +belongs in reality to his father and mother, but of all things +necessary for him he has the free and unquestioned use. Unless his +attention has been specially directed to the conception of ownership +and the nature of theft, he may not have reasoned very closely on the +matter at all. Very probably he knows that it is wrong to take what is +not given him, but he does not regard helping himself to some dainty +from a cupboard as more than an act of disobedience to authority. He +may have imbibed no ideas which place the abstraction of money from a +purse belonging to his parents on a different plane, and which have +taught him to regard such an action as especially dishonourable and +criminal. Finally, a child who, undetected, has more than once taken +money belonging to his father and mother, may pass without much +thought to steal from a visitor or a servant. To deal with such a case +effectively, to ensure that it shall never happen again, requires much +insight. If the father, shocked beyond measure to find his son an +incipient criminal, differing in his guilt in no way from boys who are +sent to reformatories as bad characters, convinces the child that +although he did not realise it, he has shown himself unworthy of any +further trust, untold harm will be done. Almost certainly the child +will act in the future according to the suggestions which are thus +implanted in his mind. If the household eyes him askance as a thief, +if confidence is withdrawn from him, he sees himself as others see him +and will react to the suggestions by repeating the offence. The +seriousness of what he has done should be explained to him, and after +due punishment he must be restored completely and ostentatiously to +absolute trust. Only by showing confidence in him can we hope to do +away with the dangers of the whole incident. To inculcate good habits +and encourage good behaviour we must let the child build up his own +reputation for these virtues. It need not make him priggish or +self-satisfied if parents let him understand that they take pride in +seeing him practise and develop the virtue they aim at. For example, +it is desired above all that he should always speak the truth. Then +they must ostentatiously attach to him the reputation of truthfulness +and show their pride in his possessing it. If he falls from grace they +must remember that he is still a child, and that if that reputation is +lightly taken from him and he is accused of a permanent tendency +towards untruthfulness, he is left hopeless and resigned to evil. Let +any mother make the experiment of presenting to her child in this way +a reputation for some particular virtue. For example, if an older +child shows too great a tendency to tease and interfere with the +younger children, let the mother seize the first opportunity which +presents itself to applaud some action in which he has shown +consideration for the others. Let her comment more than once in the +next few days on how careful and gentle the older child is becoming in +his behaviour to the little ones, and in a little the suggestion will +begin to act until the transformation is complete. If, on the other +hand, the mother adopts the opposite course and rebukes the child for +habitual unkindness, she will be apt to find unkindness persisted in. +The criminal records of the nation show too often the truth of the +saying that "Once a thief always a thief." Deprived of his good +repute, man loses his chief protection against evil and his incentive +to good. + +The inability of a child--and especially of a nervous and sensitive +child--to form conceptions of his own individuality except from ideas +derived from the suggestions of others, gives us the key to our +management of him and to our control of his conduct. He has, as a +rule, a marvellously quick perception of our own estimate of him, and +unconsciously is influenced by it in his conception of his own +personality, and in all his actions. Parents must believe in his +inherent virtue in spite of all lapses. If they despair it cannot be +hid from the child. He knows it intuitively and despairs also. It is +then that they call him incorrigible. If it happens that one parent +becomes estranged from the child, despairs of all improvement, and +sees in all his conduct the natural result of an inborn disposition to +evil, while the other parent holds to the opinion that the child's +nature is good, and to the belief that all will come right, then often +enough the child's conduct shows the effect of these opposite +influences. In contact with the first he steadily deteriorates, +affording proof after proof that judgment against him has been rightly +pronounced. In contact with the other, though his character and +conduct are bound to suffer from such an unhappy experience, he yet +shows the best side of his nature and keeps alive the conviction that +he is not all bad. + +The force of suggestion is still powerful to control conduct and +determine character in later childhood. The impetus given by the +parents in this way is only gradually replaced by the driving power of +his own self-respect--a self-respect based upon self-analysis in the +light of the greater experience he has acquired. + + + + +CHAPTER X + +NERVOUSNESS IN OLDER CHILDREN + + +In older children the line which separates naughtiness, fractiousness, +and restlessness from definite neuropathy begins to be more marked. +The nature of the young child, taking its colour from its +surroundings, is sensitive, mobile, and inconstant. With every year +that passes, the normal child loses something of this impressionable +and fluid quality. With increasing experience and with a growing power +to argue from ascertained facts, character becomes formed, and if +tempered by discipline will come to present a more and more unyielding +surface to environment, until finally it becomes set into the +stability of adult age. + +We may perhaps, with some approach to truth, look upon the adult +neurotic as one whose character retains something of the +impressionable quality of childhood throughout life, so that, to the +last, environment influences conduct more than is natural. + +All the emotions of neurotic persons are exaggerated. Disappointments +over trifles cause serious upsets; grief becomes overmastering. +Violent and perhaps ill-conceived affection for individuals is apt to +be followed by bitter dislike and angry quarrelling. On the physical +side, sense perception is abnormally acute, and many sensations which +do not usually rise up into consciousness at all become a source of +almost intolerable suffering. To these most unhappy people summer is +too hot and winter too cold; fresh air is an uncomfortable draught, +while too close an atmosphere produces symptoms of impending +suffocation. + +In some neurotics there is an excessive interest in all the processes +of the life of the body, and when attention is once attracted to that +which usually proceeds unconsciously, symptoms of discomfort are apt +to arise. Thus so simple an act as swallowing may become difficult, or +for the time being impossible. To breathe properly and without a sense +of suffocation may seem to require the sustained attention of the +patient; or again, the voice may be suddenly lost. + +More commonly, perhaps, neuropathy exhibits itself in an undue +tendency to show signs of fatigue upon exertion of any sort, mental or +physical. Sustained interest in any pursuit or task becomes +impossible. Nameless fears and unaccountable sensations of dread +establish themselves suddenly and without warning, and may be +accompanied on the physical side by palpitation, flushing, headache, +or acute digestive disturbances. + +All these manifestations are best controlled by selecting a suitable +environment, and as a rule the character of the environment is +determined by the temperament and disposition of those who live in +close contact with the patient. Like the tiny children with whom we +have dealt so far, the behaviour of neuropathic persons is subject +wholly to the direction of stronger and more dominant natures. With +faulty management at the hands of those around them, no matter how +loving and patient these may be, the conduct of the neurotic tends to +become abnormal. + +In children beyond earliest infancy we recognise a gradual approach to +the conditions of adult life. Fractiousness and naughtiness, +ungovernable fits of temper, inconsolable weeping and inexplicable +fears should disappear with early childhood even if management has not +been perfect. If they persist to older childhood we shall find in an +increasing percentage of cases evidence of definite neuropathic +tendencies which urgently call for investigation and for a precise +appreciation of the nature of the abnormality. It may be that the only +effective treatment is that which we recognise as essential in the +grosser mental disturbances--removal from the surroundings in which +the abnormal conduct has had free play, and separation from the +relatives whose anxiety and alarm cannot be hidden. + +In young nervous children fear is the most prominent psychical +symptom. The children are afraid of everything strange with which they +come in contact. They are afraid of animals, of a strange face, or an +unfamiliar room. Older children usually manage to control themselves, +suppress their tears, and prevent themselves from crying out, but it +is nevertheless easy to detect the struggle. + +Often we find those distressing attacks to which the name +"night-terrors" has been given. The child wakes with a cry,--usually +soon after he has gone to sleep,--sits up in bed and shows signs of +extreme terror, gazing at some object of his dreams with wide-open +startled eyes, begging his nurse or mother to keep off the black dog, +or the man, or whatever the vision may be. Even after the light is +turned up and the child has been comforted, the terror continues, and +half an hour may elapse before he becomes quiet and can be persuaded +to go back to bed. In the morning as a rule he remembers nothing at +all. + +Phobias of all sorts are common in nervous children, and result from a +morbid exaggeration of the instinct for self-preservation. Some cannot +bear to look from a height, others grow confused and frightened in a +crowd; dread of travelling, of being in an enclosed space such as a +church or a schoolroom, or of handling sharp objects may develop into +a constant obsession. I have known a little girl who was seized with +violent fear whenever her father or mother was absent from the house, +and she would stand for hours at the window in an agony of terror lest +some harm should have befallen them. As if with some strange notion of +propitiating the powers of darkness these children will often +constantly perform some action and will refuse to be happy until they +have done so. The same little girl who suffered such torments of +anxiety in her parents' absence would always refuse to go to bed +unless she had stood in turn on all the doormats on the staircase of +her home. Other children feel themselves forced to utter certain words +or to go through certain rhythmical movements. They fully understand +that the fear in their mind is irrational and devoid of foundation, +but they are unable to expel it. Often it is hugged as a jealous +secret, so that the childish suffering is only revealed to others +years afterwards, when adult age has brought freedom from it. We will +do well to try by skilful questioning to gain an insight into the +mental processes of a child when we find him showing an uncontrollable +desire to touch lamp-posts or to stand in certain positions; or when +he develops an excessive fear of getting dirty, or is constantly +washing his hands to purify them from some fancied contamination. + +The treatment of all these symptoms calls for much insight. The +child's confidence must be completely secured, and he must be +encouraged to tell of all his sensations and of the reasons which +prompt his actions. The nervous child has a horror of appearing unlike +other children, and will suffer in silence. If his troubles are +brought into the light of day with kindness and sympathy they will +melt before his eyes. Even night-terrors are, as a rule, determined by +the suppressed fears of his waking hours. If they are provoked by his +experiences at school, by the fear of punishment or by dismay at a +task that has proved beyond his powers, he should be taken away from +school for the time being. Night-terrors are said to be aggravated by +nasal obstruction due to adenoid vegetations. Clothing at night should +be light and porous, and particular attention should be paid to the +need for free ventilation. + +We have spoken in an earlier chapter of the trouble sometimes +experienced in inducing a nervous child to go to sleep. In older +children insomnia is common enough. Even when sleep comes it may be +light and broken, as though the child slept just below the surface of +consciousness and did not descend into the depths of sound and +tranquil slumber. We have often noticed how different is the estimate +of the patient from that of the nurse as to the number of hours of +sleep during the night. The sick man maintains that he has hardly +slept at all, whilst the nurse, drawing us aside, whispers in our ear +that he has slept most of the night. In estimating sleep we have to +consider not only its duration, but also its depth, and the patient +who denies that he has slept at all has lain perhaps half the night +with an active restless brain betwixt sleep and wakefulness. Often +enough when he comes to consider in the morning the problems that +vexed his soul at midnight, he is quite unable to recall their nature, +and recognises them as the airy stuff that dreams are made of. +Although in a sense asleep he may have retained a half-consciousness +of his surroundings and a sense of despair at the continued absence of +a sounder sleep. + +With nervous children we are apt to find sleep which is of little +depth and which constantly shows evidence of a too-active brain. The +body is tossed to and fro, words are muttered, and the respiration is +hurried and with a change in rhythm, because there is no depth of +anæsthesia. The body still responds to the impulses of the too-active +brain. From the nature of his dream--as shown by chance words +overheard--we may sometimes gather hints to help us to find where the +elements of unrest in his daily life lie. Sleep-walking is only a +further stage in this same disorder of sleep, in which the dream has +become so vivid that it is translated into motor action. + +If a child begins to suffer from active sleeplessness we must not make +the mistake of urging him to sleep. He is no more capable than we are +ourselves of achieving sleep by an effort of will power. To urge him +to sleep is likely to cause him to keep awake because we direct his +attention to the difficulty and make him fear that sleep will not +come. If he understands that all that he needs is rest, he will +probably fall asleep without further trouble. + +Day-dreams also may become abnormal, and tell of an unduly nervous +temperament. Any one who watches a little child at play will realise +the strength of his power of imagination. The story of Red Riding Hood +told by the nursery fire excites in the mind of the child an +unquestioning belief which is never granted in later life to the most +elaborate efforts of the theatre. All this imaginative force is +natural for the child. It becomes abnormal only when things seen and +acts performed in imagination are so vivid as to produce the +impression of actual occurrences, and when the child is so under the +sway of his day-dreams that he fails to realise the difference between +pretence and reality. Imagination which keeps in touch with reality by +means of books and dolls and toys is natural enough. Not so +imagination which leads to communion with unseen familiars or to acts +of violence due to the organisation of "conspiracies" or "robber +bands" amongst schoolboys. + +If evidence of abnormal imagination appears, the child must be kept in +close touch with reality. We must give him interesting and rational +occupation, such as drawing, painting, the making of collections of +all sorts, gardening, manual work, and so forth. In older children we +must especially supervise the reading. + +In many nervous children we find a faulty contact with environment, so +that instead of becoming interested in the thousand-and-one happenings +of everyday life and experiences, they become introspective and +self-conscious. As a result, sensations of all sorts, which are +commonly insufficient to arouse the conscious mind, attract attention +and, rising into consciousness, occupy the interest to the exclusion +of everything else. The conscious mind is not capable of being +occupied by more than one thing at a time. If attention is +concentrated upon external matters, bodily sensations, even extreme +pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells +us, hardly feels the scalping-knife as he shouts his death song. The +soldier in the excitement of battle is often bereft of all sense of +pain. On the other hand, the patient who is morbidly self-conscious +becomes oblivious of his surroundings while he suffers intensely from +sensations which are usually not appreciated at all. Self-conscious +children will complain much of breathlessness and a sense of +suffocation, of headache, of palpitation, of intolerable itching, of +the pressure of clothing, or of flushing and a sense of heat. +Excessive introspection influences their conduct in many ways. At +children's parties, for example, they will be found wandering about +unhappy, dazed and unable to feel the reality of the surroundings +which afford such joy to the others; or they may be anxious to join in +play, but finding themselves called upon to take their turn are apt to +stand helplessly inactive, or to burst into tears. At school, though +they may be really quick to learn, they will often be found oblivious +of all that has gone on around them, not from stupidity, but from +inability to dissociate their thoughts from themselves and to +concentrate attention upon the matter in hand. In such a case we must +aim at developing the child's interest to the exclusion of this morbid +introspection. Taking advantage of his individual aptitude, we must +strengthen his hold upon externals in every way possible, and we must +explain to him the nature of his failing and teach him that his +salvation lies in cultivating his capacity for paying attention to +things around him and developing an interest in suitable occupations. + +Fainting fits are not uncommon amongst nervous children from about +the sixth year onwards, and are apt to give rise to an unwarranted +suspicion of epilepsy. In other cases fears have been aroused that the +heart may be diseased. In children who faint habitually the nervous +control of the circulation is deficient. We notice that when they are +tired by play, or when they are suffering from the reaction that +follows excitement of any sort, the face is apt to become pale, and +dark lines may appear under the eyes. Yet there may be no true anæmia +present: it is only that the skin is poorly supplied with blood for +the moment. After a little rest in bed, or under the influence of a +new excitement, the colour returns, and the tired look vanishes. If +children of this type are made to stand motionless for any length of +time, and if at the same time there is nothing to attract their +interest or attention--a combination of circumstances which unhappily +is sometimes to be found during early morning prayers at school--the +want of tone in the blood vessels may leave the brain so anaemic that +fainting follows. The first fainting attack is a considerable +misfortune, because the fear of a recurrence is a potent cause of a +repetition. Standing upright with the body at rest and the mind +vacant, the circulation stagnates, the boy's mind is attracted by the +suggestion, he fears that he will faint as he has done before, and he +faints. Schoolmasters are well aware that if one or two boys faint in +chapel and are carried out, the trouble may grow to the proportion of +a veritable epidemic. It is important that this habit of fainting +should be combated not only by general means to improve the tone of +the body and circulation, but also by taking care that the child +understands the nature of the fainting fit, and the part which +association of ideas plays in producing it. Disease of the heart +seldom gives rise to fainting. + +The same vasomotor instability which shows itself in the tendency to +syncopal attacks is apparent in many other ways. Sudden sensations of +heat and of flushing, equally sudden attacks of pallor, coldness of +the extremities, abundant perspiration,--raising in the mind of the +anxious mother the fear of consumption,--and excessive diuresis are +common accompaniments. A further group of symptoms is provided by the +extreme sensibility of the digestive apparatus. Dyspepsia, +hyperaesthesia of the intestinal tract, viscero-motor atonies and +spasms, and anomalies of the secretions, whether specific like that of +the gastric juice or indifferent like that of the nasal, pharyngeal, +gastric, and intestinal mucus, are all of common occurrence. Whenever +the nervous child is subjected to any exhausting experience, any +excitement, pleasurable or the reverse, or any undue exertion, whether +mental or physical, one may note the subsequent gastro-intestinal +derangement, including even a coating of the tongue. The slightest +deviation from the usual diet, the most trivial fatigue, a chill of +the body, even a change in the temperature of the food may set loose +the most extreme reactions in the gastro-intestinal tract--motor, +sensory, or secretory. It is not an accident that so often the mucous +diarrhoea, which may have afflicted an excitable child in London for +many months, and which a visit to the seaside, with all its healthy +activities, may seem to have completely cured, relapses within a day +or two of the return to the restricted environment and uninteresting +routine of life in London. The child who was happy and busy and at +peace with himself, at play in the open air, resents the sudden +cessation of all this, and the nervous unrest returns. To attempt +treatment by dietetic restrictions alone is to deal only with a +symptom. The gastro-intestinal reactions are so violent that the +parents are generally voluble on the subject of the many foods which +cannot be taken and the few which are not suspect. To prescribe rigid +tables of diet is to add to the alarm of the mother, and to sustain +her in the belief that the child is in daily danger of being poisoned +by a variety of common articles of diet. Only by lowering the +excitability of the nervous system, by occupying the mind and giving +strength to the child's powers of control can we effectively combat +the hyperaesthesia. If necessary the personnel of the management of +the child will have to be altered. There may be no other way to +achieve certain and rapid improvement in a condition which is causing +grave danger to the child and very genuine distress and suffering to +the parents. A violent reaction to intoxications of all sorts is a +further stigma of nervous instability. Sudden and even inexplicable +rises of temperature are frequent complaints, and the constitutional +effects of even trivial local infections are apt to be +disproportionately great. + +Fatigue is easily induced and is exhibited in all varieties of +activity--mental, physical, or visceral. Mental work may produce +fatigue with extreme readiness even although the quality of the work +may remain of a high standard. To Darwin and to Zola work for more +than three hours daily was an impossibility, and yet their work done +under these restrictions excites all men's admiration. The palpitation +and breathlessness which follows upon trivial exertion, such as +climbing a flight of stairs, is a good example of visceral fatigue. + +Among adult neuropaths we recognise the harm which may be done by +unwise speeches on the part of relatives, or still more on the part of +doctors. A chance word from a doctor or nurse off their guard for the +moment will implant in the minds of many such a person the unyielding +conviction that he or she is suffering from some gastric complaint, +from some cardiac affection, or from some constriction of the bowel. +It may take the united force of many doctors to uproot this +pathological doubt which was implanted so easily and so carelessly. +The medical student is notoriously prone to recognise in himself the +symptoms of ailments which he hears discussed. Little children, too, +are apt to suffer in the same way. How much illness could be avoided +if mothers would cease to erect some single manifestation of +insufficient nervous control into a local disorder which becomes an +object of anxiety to the child and to the whole household. + +Undue liability to fatigue, irritability, instability, lack of +control over the emotions, extreme suggestibility, prompt and +exaggerated reactions to toxins of all sorts, excessive vasomotor +reactions and anomalies of secretion, weakness of the +gastro-intestinal apparatus--these, and many other symptoms, are of +everyday occurrence in the nervous child. To discuss them more fully +would be to pass too far from our nursery studies into a consideration +of psychological medicine. + + + + +CHAPTER XI + +NERVOUSNESS AND PHYSIQUE + + +It has already been said that symptoms of nervousness are often +accompanied by faults in the physical development of the child. The +defects may assume so many forms as to make any attempt at description +very difficult. Nevertheless, certain types of physical defect present +themselves with sufficient frequency, in combination with neurosis, to +merit a detailed description. For example, we recognise a type of +nervous child which is marked by a persistence into later childhood of +certain infantile characteristics of the build and shape of body. +Further, we meet with a group characterised by a special want of tone +in the skeletal muscles, by lordosis, by postural albuminuria, and by +abdominal and intestinal disturbances of various sorts. We recognise +also the rheumatic type of child with a tendency to chorea, and in +contrast to this a type with listlessness, immobility, and katatonia. +Lastly, in a few children, in boys as well as in girls, we may meet +with cases of hysteria.[3] + +[Footnote 3: If we accept as hysterical all symptoms which are +produced by suggestion and which can be removed by suggestion, we may +correctly speak of a physiological hysteria of childhood, which +includes a very large number of the symptoms discussed. The term is +used here in its older more limited sense.] + +(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS + +During the first year or eighteen months of life, the rounded +infantile shape of body persists. The limbs are short and thick, the +cheeks full and rounded, the thorax and pelvis are small, the abdomen +relatively large and full. The great adipose deposit in the +subcutaneous tissue serves as a depôt in which water is stored in +large amounts. In the healthy child of normal development by the end +of the second year a great change has taken place. The shape of the +body has become more like that of an adult in miniature. The limbs +have grown longer and slimmer. The thorax and pelvis have developed so +as to produce relatively a diminution in the size of the abdomen. The +body fat is still considerable, but no longer completely obliterates +the bony prominences of the skeleton. Delay in this change, in this +putting aside of the infantile habit of body, is commonly associated +with a corresponding backwardness in the mental development. Such +children walk late, talk late, learn late to feed themselves, to bite, +and to chew effectively. Watery and fat, they carry with them into +later childhood the infantile susceptibility to catarrhal infections +of the lung, bowel, skin, etc., and they are apt to suffer, in +consequence, from a succession of pyrexial attacks. Nasal catarrh, +bronchitis, otitis media, enteritis, eczema, urticaria papulata, are +apt to follow each other in turn, giving rise in many cases to a +persistent enlargement of the corresponding lymphatic glands. The +effect upon the different tissues of the body of these repeated +infections is very various. We are probably not wrong in attributing +the failure to develop and the persistently infantile appearance to a +prejudicial effect upon the various ductless glands in the body. The +condition is associated with an excessive retention of fluid in the +body, secondary in all probability to alterations in the concentration +and distribution of the saline constituents of the body. A rapid +excretion of salts may be followed by a correspondingly speedy +dehydration of the body, a retention of salts by a sudden increase of +weight. The parathyroid glands are probably closely concerned in +regulating the retention and excretion of salts, and especially of +calcium, a circumstance which becomes of significance when we remember +how frequently rickety changes, tetany, and other convulsive seizures +form part of the clinical picture which we are now considering. While +it is difficult to determine the effect of repeated infections upon +the functions of the endocrine glands, we have clear evidence of the +deleterious influence upon almost all the tissues of the body, the +functioning of which it is more easy to estimate. For example, the +cells of the skin and of the mucous membranes which happen to be +visible to the eye show clear evidence of diminished vitality and +increased vulnerability. Physiological stimuli, incapable of producing +any visible reaction in healthy children, habitually determine widely +spread and persistent inflammatory reactions. For example, the +licking movements of the tongue at the corners of the mouth produce +the little unhealthy fissures which the French call _perlèche_. The +physiological stimulus of the erupting tooth is capable of causing a +painful irritation of the gum, so that the child is said to suffer +from teething, accompanied, it may be, and the association is +significant, by "teething convulsions." The irritation of the urine +produces rawness and excoriation of the skin of the prepuce, contact +with intestinal contents not in themselves very abnormal, an +intractable dermatitis of the buttocks or a persistent diarrhoea and +enteral catarrh. Improvement in the general health, the result of the +cessation for the time being of the recurrent infections, perhaps +consequent upon improved hygienic conditions, always determines the +rapid disappearance of all these accompaniments of the general +diminution of tissue vitality. + +The muscular system and the bones are commonly also involved, so that +rickety changes are often found in these infantile and watery +children. In early childhood the processes of calcification and +decalcification proceed side by side and with great rapidity, and in +health there is always a balance on the side of the constructive +process. In the children whom we are now considering, saturated as +they are, from time to time, with the toxins resulting from repeated +infection, ossification may be so interfered with as to cause +softening and bending, with the evolution of a state of rickets. +Between bone and muscle, too, we find a close relationship. We do not +find powerful muscles with softened bone, nor flabby muscle with +rigid and well-formed bone. + +In the nervous system, the conditions are somewhat different. In skin, +in bone, and in muscle new cell elements are constantly being formed, +and the life of the individual cell is relatively short. In the +nervous system, on the other hand, the individual cells are long +lived. Their life-history may even be coterminous with that of the +individual, and if destroyed they are not replaced. Nevertheless, they +do not escape undamaged in the general disturbance. In a deprivation +of calcium we have, in all probability, the explanation of the +increased irritability of peripheral nerves and of the tendency to +convulsive seizures of all sorts which is a common accompaniment of +the condition. Convulsions, laryngismus stridulus, tetany, or +carpopedal spasm are all frequently met with. In crying, the children +hold their breath to the point of producing extreme cyanosis, ending, +as the spasm relaxes, with a crowing inspiration, which resembles and +yet differs in tone from both the whoop of whooping-cough and the +crowing inspiration of croup. + +Apart, however, from this tendency to convulsive seizures the nervous +system of these children is abnormal. As a rule they are excitable, +and develop late the power to control their emotions. Lagging behind +in physical development and in the capacity to interest themselves in +the pursuits of normal children, their emotional state remains that of +a much younger child. In the infant classes at schools they are +recognised as dullards, learning slowly, speaking badly, and lacking +co-ordination in all muscular movements. + +The clinical picture so depicted is encountered with extreme frequency +among the children of the poor in our large cities. To find a name for +the condition is no easy matter. To call it "rickets" is to place an +undue emphasis upon the bony changes which, though common, are by no +means invariable. Elsewhere I have suggested the name status +catarrhalis, on an analogy with the name status lymphaticus, which in +the post-mortem room is used to describe the secondary overgrowth of +lymphatic tissue which is found in these catarrhal children. In the +present connection it is of interest to us to note how commonly the +nervous system is involved in the general picture and the frequency +both of convulsive disorders and of neuropathy. + +The nervous symptoms of both sorts are to be allayed only by improving +the general hygiene of the child and raising its resistance against +infection. A sufficiency of fresh air and of sunlight, and a +management which encourages independence of action in the child, are +both necessary. The diet is of the first importance. It should be +sufficient, and no more than sufficient, to cover the physiological +needs of the child for food. The majority of these children have +enormous appetites, and excess of food, and especially of carbohydrate +food, plays some part in the production of the disturbance. We must +guard against overfeeding, against want of air and want of exercise, +and against those errors of management described in previous chapters, +which produce the maximum of disturbance in this type of child. + + +(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA + +At an older age, in children from the fifth year onwards, a second +type of physical defect associated with pronounced nervous disturbance +presents itself with some frequency. The body is thin and badly +nourished, and the muscular system especially poorly developed and +very lax in tone. The most striking feature is the extreme lordosis, +accompanied usually by a secondary and compensatory curve in the +cervico-dorsal region, so that the shoulders are rounded, with the +head poked forward. Viewed from in front the abdomen is seen to be +prominent, overhanging the symphysis pubis, while the shoulders have +receded far backwards. The scapulæ have been dragged apart, as though +by the weight of the dependent arms, with eversion of their vertebral +borders and lowering of the points of the shoulders. The position +which they adopt is that into which the body falls when it ceases to +be braced by strong muscular support. The muscular system is here so +weakly developed and so toneless that the posture is determined by the +bony structure and its ligamentous attachments. + +The lordosis resembles the similar deformity which develops in cases +of primary myopathy, when the spinal muscles have undergone complete +atrophy. As in myopathy the movements are very uncertain. The +children are apt to fall heavily when the centre of gravity is +suddenly displaced, because their upright posture is maintained by +balancing the trunk upon the support of the pelvis. The frequency and +severity of the falls which these children suffer is a common +complaint of the mother. The faulty posture is often associated with +slight albuminuria. Its appearance is very capricious, but it is +dependent to a great extent upon the assumption of the erect posture. +There has been much discussion as to its explanation. It has been +argued that the lordosis itself produces the albuminuria by mechanical +compression of the renal vein, and it is said that albuminuria can be +produced, even in the prone position, by placing the child in a +plaster jacket applied so as to maintain the position of lordosis. +Other observers, however, have not obtained this result. It seems most +likely that the albuminuria is due to defective tone in the vasomotor +musculature, comparable in every way to the defective tone in the +muscles of the skeleton. We have often further evidence of vasomotor +weakness. Fainting attacks are so common as to be the rule rather than +the exception. Again, mothers are likely to complain of the child's +pallor and of dark lines under the eyes, especially after exertion or +in the reaction which follows excitement of any sort. As a rule a +blood count will not show any very striking evidence of true anæmia. +The pallor is of vasomotor origin, determined by faults in the +distribution of the blood from vasomotor weakness and not by deficient +blood formation. Circulatory and vasomotor disturbance probably also +accounts for the dyspeptic pains and vomiting which commonly accompany +any emotional excitement, or follow any unusual exertion or fatiguing +experience. Constipation is a common, and mucous diarrhoea an +occasional, symptom. The abdomen is often pigmented. The hands and +feet are usually cold and cyanosed. + +The extreme nervousness of the children is the point upon which most +stress may be laid in the present connection. The association of +albuminuria with neurosis in childhood has been noticed by many +observers. The gastric and intestinal symptoms are especially +characteristic. If the condition of the children is not materially +improved, and if the symptoms, both of the physical defect and of the +nervous disturbance, are not cut short, we may predict that in adult +age their lives will be made miserable by a variety of abdominal +symptoms dependent both on the vasomotor disturbance and upon the +accompanying neurosis. Now that surgery forms so large a part of our +therapeutic proceedings, they may not reach middle life without being +submitted to one or more surgical operations. With good management +both on the physical side and on the moral or psychological side they +can be made into strong and useful members of society. + +The treatment of these cases may be summed up as follows: + +_(a)_ We must search for any source of infection, a source which is +often to be found in the condition of the tonsils. Enucleation may +then be indicated as the first step in treatment. + +_(b)_ Massage and gymnastic exercises calculated to improve the +muscular tone, while every effort is made to secure for the child as +perfect hygiene in the environment as possible. + +_(c)_ The stimulating effect of cold douches is often very evident in +improving the vasomotor tone. These children, however, will not stand +well the abstraction of heat from their thin and chilly little bodies, +so that it is a good plan before the colder douche to immerse the +child in a hot bath and to return again to the bath momentarily +afterwards. With these precautions children will often enjoy a cold +spray, the temperature of which may be constantly lowered as they +become used to it. Prolonged hot bathing has a correspondingly +prejudicial effect. + +_(d)_ We must be on the watch to prevent the development of further +postural deformities, such as scoliosis. If a child of strong muscular +tone and good physique habitually adopts some posture, curled up, it +may be, in some favourite easy-chair, there is little likelihood that +its constant assumption will produce deformity. When the muscular +system is lax and weak, on the other hand, deformity such as scoliosis +is very readily caused. It is important, for example, to see that the +child does not habitually incline to one side in reading or writing. +When there is little energy for free and energetic play the children +are apt to become great bookworms. If there is shortsightedness, the +dangers are correspondingly increased. A special chair may be made +with a well-fitting back and the seat a little tilted upwards so as to +throw the child's trunk on to the support of the back. Lastly, a desk, +the height of which can be regulated at will, can be swung into the +proper position. The child, sitting straight and square, with the +weight supported by the foot-rest and back as well as by the seat of +the chair, should be taught to write with an upright hand, avoiding +the slope which leads to sitting sideways with the left shoulder +lowered. + +(e) Malt extract, cod liver oil, Parrish's food, and other tonics may +be of undoubted service. + + +(3) RHEUMATISM AND CHOREA + +It is certain that there is a close association between rheumatism in +childhood and the common nervous affection known as chorea. We are +still ignorant of the precise nature of the infection which we know as +rheumatism. There is much to suggest that in rheumatism we have to +deal only with a further stage in those catarrhal infections to which +so much infantile ill-health is to be attributed, and that +endocarditis and arthritis, when they arise, signalise the entry of +these catarrhal, non-pyogenic organisms into the blood stream, +overcoming at last the barrier of lymphoid tissue which has +hypertrophied to oppose their passage. Certainly the connection of +rheumatism with catarrhal infections of the mucous membranes and +adenoid enlargements of all sorts is a close one. Whatever its +nature, the rheumatic infection in childhood is more lasting and +chronic than in adult life. Rheumatism in childhood is not manifested +by acute and short-lived attacks of great severity so much as by a +long-continued succession of symptoms of a subacute nature, a +transient arthritis, perhaps, succeeding an attack of sore throat with +torticollis, to be followed by carditis, to be followed again by +another attack of tonsillitis. And so the cycle of symptoms revolves. +In most cases the child grows thin and weak; in most cases he becomes +restless, irritable, and unhappy; often there is definite chorea. Of +this cerebral irritability chorea is the expression. In adults, chorea +is perhaps more obviously associated with mental stress of all sorts +and with states of excitement and agitation. In the case of little +children it is often only the mother who really appreciates how +radical an alteration the child's whole nature has undergone, and how +great the element of nervous overstrain has been before the chorea has +appeared. + +Of the treatment of chorea there is no need to speak. It is purely +symptomatic. Isolation, best perhaps away from home, as might be +expected, gives the best results. If there are pronounced rheumatic +symptoms, the salicylates will be needed; if there is anæmia, arsenic +and iron; if there is sleeplessness and great restlessness, bromides +or chloral. Hypnotism is often almost instantly successful, but, apart +from hypnosis, curative suggestions proceeding from the attendants +form the principal means at our disposal. + + +(4) EXHAUSTION AND KATATONIA + +A large number of children, in convalescence from infective disorders, +when the nutrition of the body has fallen to a low ebb, show as +evidence of cerebral exhaustion a group of symptoms which in a sense +are the reverse of those which characterise cerebral irritation and +chorea. The healthy child is a creature of free movement. The children +we are now considering will sit for a long time motionless. The +expression of their faces is fixed, immobile, and melancholy. If the +arm or leg is raised it will be held thus outstretched without any +attempt to restore it to a more natural position of rest for minutes +at a time. The posture and expression remind us at once of the +katatonia which is symptomatic of dementia præcox and other stuporose +and melancholiac conditions in adult life. Symptoms of this sort are +especially common in children with intestinal and alimentary +disturbances of great chronicity. + +The symptom is so frequently met with that it is strange that it +should have attracted so little attention as compared with the +contrasting condition of chorea. And yet it is of more serious +significance, more difficult to overcome, and with a greater danger +that permanent symptoms of neurasthenia will result. In early +childhood a careful dietetic régime, suitable hygienic surroundings, +and a stimulating psychical atmosphere will often effect great +improvement. As in chorea, however, relapses are frequent, and there +are cases which for some unexplained reason are peculiarly resistant +to all remedial influences. + + +(5) HYSTERIA + +In hysteria, in contrast to the types previously described, the +infective element may be completely absent. Except in some special +features of minor importance the symptoms of hysteria do not differ +from those of adults, and, as in adult age, the condition of hysteria +may be present although the physical development may be perfect. We +cannot here speak of any physical characteristics which are associated +with the nervous symptoms. + +The third or fourth year represents the age limit, below which +hysterical symptoms do not appear. Thereafter they may be occasionally +met with, with increasing frequency. At first, in the earlier years of +childhood, there is no preponderance in the female sex. As puberty +approaches, girls suffer more than boys. + +It may be said to be characteristic of hysteria in childhood that its +symptoms are less complex and varied than in adult life. The naive +imagination of the child is content with some single symptom, and is +less apt to meet the physician half-way when he looks for the +so-called stigmata. Similarly mono-symptomatic hysteria is +characteristic of oases occurring in the uneducated or peasant class. +In children, hysterical pain, hysterical contractures or palsies, +mutism, and aphonia are the most usual symptoms. Hysterical deafness, +blindness, and dysphagia are manifestations of great rarity in +childhood. + + + + +CHAPTER XII + +THE NERVOUS CHILD IN SICKNESS + + +In time of sickness the management of the nervous child becomes very +difficult. Restlessness and opposition may reach such a pitch that it +may be almost impossible to confine the patient to bed or to carry out +the simplest treatment. Sometimes days may elapse before the +sick-nurse who is installed to take the place of the child's usual +attendant is able to approach the cot or do any service to the child +without provoking a paroxysm of screaming. In such a case any +systematic examination is often out of the question, with the result +that the diagnosis may be delayed or rendered impossible. There is +only one reassuring feature of a situation, which arises only in +nurseries in which the management of the children is at fault; the +doctor has learned from experience that this pronounced opposition of +the child to himself, to the nurse, and even to the mother, is of +itself a reassuring sign, indicating, as a rule, that the condition is +not one of grave danger or extreme severity. When the child is more +seriously ill, opposition almost always disappears, and the child lies +before us limp and passive. Only with approaching recovery or +convalescence does his spirit return and renewed opposition show +itself. + +Extreme nervousness in childhood carries with it a certain liability +towards what is known as "delicacy of constitution." The sensitiveness +of the children is so great that they react with striking symptoms to +disturbances so trivial that they would hardly incommode the child of +more stable nervous constitution. For example, a simple cold in the +head, or a sore throat, may cause a convulsion or a condition of +nervous irritability which may even arouse the suspicion that +meningitis is present. Or, again, a little pharyngeal irritation which +would ordinarily be incapable of disturbing sleep may be sufficient to +keep the child wide awake all night with persistent and violent +coughing. The little irritating papules of nettlerash from which many +children suffer are commonly disregarded by busy, happy children +during the day, and even at night hardly suffice to cause disturbance. +The nervous child, on the other hand, will scratch them again and +again till they bleed, tearing at them with his nails, and making deep +and painful sores. + +The temperature is commonly unstable and readily elevated. Moreover, +feverishness from whatever cause is often accompanied by an active +delirium, which is apt to occasion unnecessary alarm. This symptom of +delirium is always a manifestation of an excitable temperament. I +remember being called to see a young woman who was thought to be +suffering from acute mania. Examination showed that she was suffering +from pneumonia in the early stages. It was only later that we +discovered that she had always been of an unstable nervous +temperament, and had been in an asylum some years before. Those of us +who are fortunate in possessing a placid temperament and have +developed a high degree of self-control are not likely to show +delirium as a prominent symptom should we fall ill with fever; just as +we should not struggle and scream too violently when we "come round" +from having gas at the dentist's. Looked at from this point of view, +it is natural for all children to become delirious readily, and this +tendency is peculiarly marked in those who are unduly nervous. + +As a consequence of this extreme sensitiveness, the nervous child is +likely to suffer more than others from a succession of comparatively +trifling ailments and disturbances. The delicacy of the child has, in +this sense, a real existence, and is not confined to the imagination +of over-anxious and apprehensive parents. No doubt the nervous mother +of an only child does worry unnecessarily, and is far too prone to +feed her fears by the daily use of the thermometer or the +weighing-machine; but her friends who are happy in the possession of +numerous and placid children are not justified in laying the whole +blame upon her too great solicitude. Children who are members of large +families, whose nervous systems have been strengthened by contact with +their brothers and sisters, are not habitually upset by trifles, and +suffer even serious illnesses with symptoms of less severity. Nervous +children, and only children, on the other hand, show the opposite +extreme. Nevertheless, the mother of a nervous and delicate child--a +child, that is to say, who, even if he is not permanently an invalid, +nevertheless never seems quite well and lacks the robustness of other +children--should realise clearly how much of this sensitiveness is due +to the atmosphere of unrest and too great solicitude which surrounds +him. It is a matter of universal experience that excess of care for +only children has a depressing influence which affects their +character, their physical constitution, and their entire vitality. At +all costs we must hide our own anxieties from the child, and we must +treat his illnesses in as matter-of-fact a way as possible. + +When illness comes, his daily routine should be interrupted as little +as possible. In dealing with nervous children, it is often better to +lay aside treatment altogether rather than to carry out a variety of +therapeutic procedures which have the effect of concentrating the +child's mind upon his symptoms. When we grown-up people are sick, we +often find a great deal of comfort in submitting ourselves to some +form of treatment. We have great faith, we say, in this remedy or in +that. It is _our_ remedy, a _nostrum_. The physician knows well that +the opportunities which are presented to him of intervening +effectually to cut short the processes of disease by the use of +specific cures are not very numerous, and that often enough the +justification for his prescription is the soothing effect which it +may exercise upon the mind of the patient, who, believing either in +the physician or in his remedy, finds confidence and patience till +recovery ensues. As a rule this form of consolation is denied to +little children. They have no belief in the efficacy of the remedies +which are applied with such vigour and persistence. Indeed, it is not +the child, but his anxious mother, who finds comfort in the thought +that everything possible has been done. Therefore, a prescription must +be written and changed almost daily, the child's chest must be +anointed with oil, and the air of the sick-room made heavy with some +aromatic substance for inhalation, and all this when the disturbance +is of itself unimportant, and owes its severity only to the undue +sensitiveness of the child's nervous system. + +The very name of illness should be banished from such nurseries. +Everything should be done to reassure the child and to make light of +his symptoms, and we can keep the most scrupulous watch over his +health without allowing him to perceive at all that our eye is on him. +With older children the evil results of suggestions, unconsciously +conveyed to them by the apprehension of their parents, become very +obvious. The visit of the doctor, to whom in the child's hearing all +the symptoms are related, is often followed by an aggravation which is +apt to be attributed to his well-meant prescription. The harm done by +examinations, which are specially calculated to appeal to the child's +imagination, as, for instance, an X-ray examination, is often clearly +apparent. I remember a schoolboy of thirteen who was sent to me +because he had constantly complained of severe abdominal pain. He was +a nervous child with a habit spasm, the son of a highly neurotic +father and an overanxious mother. An X-ray examination was made, but +showed nothing amiss. The child's interest and preoccupation in the +examination was painfully obvious. That night his restraint broke down +altogether, and he screamed with pain, declaring that it had become +insupportable. Younger children, less imaginative but equally +perverse, noticing how anxiously their mothers view their symptoms, +will often make complaint merely to attract attention and to excite +expressions of pity or condolence. Sometimes they will enforce their +will by an appeal to their symptoms. I have had a little patient of no +more than thirteen months of age who suffered severely and for a long +time from eczema, and who in this way used his affliction to ensure +that he got his own way. If he was not given what he wanted +immediately he would fall to scratching, with an expression upon his +face which could not be mistaken. To him, poor child, the grown-up +people around seemed possessed of but one desire--to stop his +scratching; and he had learnt that if he showed himself determined to +scratch they would give way on every other point. + +The ill-effects of departing too readily from ordinary nursery routine +on account of a little illness, and of adopting straightway a variety +of measures of treatment, is well shown in cases of asthma in +children. The asthmatic child is almost always of a highly nervous +temperament, and often passionate and ungovernable. Often the most +effective treatment of an attack, which usually comes on some hours +after going to bed, is to make little of it, to talk naturally and +calmly to the child, to turn on the light, and to allow him, if he +will, to busy himself with toys or books. To be seized with panic, to +send post-haste for the doctor, to carry the patient to the open +window, to burn strong-smelling vapours, and so forth, not only is apt +to prolong the nervous spasm on this occasion, but makes it likely +that a strong impression will be left in his mind which by +auto-suggestion will provoke another attack shortly. With nervous +children a seeming neglect is the best treatment of all trivial +disorders. Meanwhile we can redouble our efforts to remedy defects in +management, and to obtain an environment which will gradually lower +the heightened nervous irritability. + +When the illness is of a more serious nature, as has been said, the +restlessness as a rule promptly disappears. In each case it must be +decided whether it is best for the child to be nursed by his mother +and his own nurse, or by a sick-nurse. In the latter event the +ordinary nurse and the mother should absent themselves from the +sick-room as much as possible. Often the firm routine of the hospital +nurse is all that is wanted to obtain rest. Less often, the child will +be quiet with his own nurse, and quite unmanageable with a stranger. + +There is, however, another side to the question. The relation of +neurosis in childhood to infection of the body is complex. I have said +that with the nervous child a trivial infection may produce symptoms +disproportionately severe. Persistent and serious infection, however, +is capable of producing nervous symptoms even in children who were not +before nervous, and we must recognise that prolonged infection makes a +favourable soil for neuroses of all sorts. The frequency with which +St. Vitus's dance accompanies rheumatism in childhood forms a good +example of this tendency. The child who, from time to time, complains +of the transient joint pains which are called "growing pains," and who +is found by the doctor to be suffering from subacute rheumatism, is +commonly restless, fretful, and nervous. Appetite, memory, and the +power of sustained attention become impaired. Often there is excessive +emotional display, with, perhaps, unexplained bursts of weeping. The +child is readily frightened, and when sooner or later the restless, +jerky movements of St. Vitus's dance appear, the usual explanation is +that some shock has been experienced, that the child has seen a street +accident, has been alarmed by a big dog jumping on her, or by a man +who followed her--shocks which would have been incapable of causing +disturbance, and which would have passed almost unappreciated had not +the soil been prepared by the persistent rheumatic infection. + +The management of the nervous child whose physical health remains +comparatively good is difficult enough, but these difficulties are +increased many times when the physical health seriously fails. To +steer a steady course which shall avoid neglecting what is dangerous +if neglected, and overemphasising what is dangerous if +over-emphasised, calls for a great deal of wisdom on the part both of +the mother and her doctor. + + + + +CHAPTER XIII + +NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS + + +In this chapter I approach with diffidence a subject which is rightly +enough occupying a great deal of attention at the present time: the +instruction of our children in the nature, meaning, and purpose of +sexual processes. It is a subject filled with difficulties. Every +parent would wish to avoid offending the sense of modesty which is the +possession of every well-trained child, and finds it difficult to +escape the feeling that discussion on such matters may do more harm +than good. There is certainly some risk at the present time that, +putting reticence on one side, we may be carried too far in the +opposite direction. The evils which result from keeping children in +ignorance are well appreciated. We have yet to determine the effect +upon them of the very frank and free exposure of the subject which is +recommended by many modern writers. Nevertheless, it must be granted +that it is not right to allow the boy or girl to approach adolescence +without some knowledge of sex and the processes of reproduction. If +nothing is said on such subjects, which in the nature of things are +bound to excite a lively interest and curiosity in the minds of older +children, evil results are apt to follow. Because parents have never +mentioned these subjects to their child, they must not conclude that +he is ignorant of all knowledge concerning them. It is not unlikely +that the question has often occupied his thoughts, and that his +speculations have led him to conclusions which are, on the whole, +true, although perhaps incorrect in matters of detail. Most children, +unable to ask their mother or father direct questions upon matters +which they feel instinctively are taboo, have pieced together, from +their reading and observation, a faulty theory of sexual life. The +pursuit of such knowledge, in secret, is not a healthy occupation for +the child. His parents' silence has given him the feeling that the +unexplored land is forbidden ground. In satisfying his curiosity he is +most certainly fulfilling an uncontrollable impulse, but he has been +forced to be secretive, and to look upon the information he has +acquired as a guilty secret. So far even the best of children will go +upon, the dangerous path. If training has been good, and if the child +has responded well to it, he will go no further. Though he can hardly +be expected to refrain from constructing theories and from testing +them in the light of any chance information which may come his way, he +will instinctively feel that the subject is one best left alone. He +will not talk of it with other boys--not even with those who are older +than himself and whose superior knowledge in all other matters he is +accustomed to respect. We need not be surprised, however, that the +majority of children do not attain to this high standard of conduct, +and that the interest and excitement of exploring the unknown and the +forbidden proves too great. Children will consult with each other +about such matters, and knowledge of evil may spread rapidly from the +older to the younger. In some schools, as is well known, there may +grow up with deplorable facility an unhealthy interest in sexual +matters. On the surface of school life all may seem fair enough, but +beneath, hidden from all recognised authority, lies much that is +unspeakable. If the boy has not been taught to have clean thoughts +upon matters which are essentially clean, if he has not learned to +know evil that he may avoid it, he may not escape great harm. The +fault in us which kept him in ignorance will recoil upon our own +heads. He will maintain the barrier which was erected in the first +place by our own unhappy reticence, and we may find it a hard task to +penetrate behind it and prevent his constant return to secret thoughts +and imaginings or secret habits and practices. Certain physiological +processes come to have for him an unclean flavour which is yet +perniciously attractive. He knows little of the real meaning of sexual +processes or of the great purpose for which they are designed. It is +only that an unhealthy interest becomes attached to all subjects which +are scrupulously avoided in general conversation. In secret he +develops a wrong attitude to all these matters. + +Oliver Wendell Holmes[4] tells us that in religion certain words and +ideas become "polarised," that is to say, charged with forces of +powerful suggestion, and must be "depolarised." + +[Footnote 4: _The Professor at the Breakfast Table_, Oliver Wendell +Holmes.] + + * * * * * + +"I don't know what you mean by 'depolarising' an idea, said the +divinity-student. + +"I will tell you, I said. When a given symbol which represents a +thought has lain for a certain length of time in the mind, it +undergoes a change like that which rest in a certain position gives to +iron. It becomes magnetic in its relations--it is traversed by strange +forces which did not belong to it. The word, and consequently the idea +it represents, is polarised. + +"The religious currency of mankind, in thought, in speech, and in +print, consists entirely of polarised words. Borrow one of these from +another language and religion, and you will find it leaves all its +magnetism behind it. Take that famous word, O'm, of the Hindoo +mythology. Even a priest cannot pronounce it without sin; and a holy +Pundit would shut his ears and run away from you in horror, if you +should say it aloud. What do you care for O'm? If you wanted to get +the Pundit to look at his religion fairly, you must first depolarise +this and all similar words for him. The argument for and against new +translations of the Bible really turns on this. Scepticism is afraid +to trust its truths in depolarised words, and so cries out against a +new translation. I think, myself, if every idea our Book contains +could be shelled out of its old symbol and put into a new, clean, +unmagnetic word, we should have some chance of reading it as +philosophers, or wisdom-lovers, ought to read it--which we do not and +cannot now, any more than a Hindoo can read the 'Gayatri' as a fair +man and lover of truth should do." + + * * * * * + +Now in the minds of many boys and some girls certain words and ideas +connected with certain physiological processes become polarised. It is +the parents' duty to depolarise them. It is a task which cannot well +be deputed to others; nor can much help be derived from books, though +many have been written with the object of initiating children into the +mysteries of sex. No one but a parent is likely to be on sufficiently +intimate terms with the child to enable the subject to be approached +without restraint or awkwardness, and no book can adapt itself to the +varying needs of individual children. An exposition in cold print, or +a single formal lecture on the subject, is apt to do more harm than +good. I have seen instructions to parents to deliver themselves of set +speeches, examples of which are given, which seem to me well +calculated to repel and frighten the nervous child. Still more +dangerous is the advice to make sexual hygiene a subject for class +study. The task requires that parents should be upon very intimate +terms with their children, and on suitable occasions, when this +feeling of intimacy is strong, children should be encouraged to speak +freely and to ask for explanations. By a judicious use of such +opportunities piece by piece the whole may be unfolded. In order that +the child may approach the subject in the proper spirit we may +stimulate interest by a few lessons in Natural History. A child of +eight or ten years of age is not too young to learn a little of the +outlines of anatomy and physiology. If he is told a few bald facts +about the skeleton, about the circulation and the processes of +digestion such as any parent can teach at the cost of a few hours' +study of a handbook, this will lead naturally enough, in later +lessons, to a similar talk upon the excretory organs, reproduction, +and the anatomy and processes of sex, suitable to the individual. To +achieve "depolarisation," there is nothing more efficacious than the +frankness and explicitness of scientific statement, however +elementary. Later a little knowledge of Botany and Zoology will enable +a parent to sketch briefly the outlines of fertilisation and +reproduction. The child may grasp the conception that the life of all +individual plants and animals is directed towards the single aim of +continuing the species. He can be told how the bee carries the male +pollen to the female flower, how all living things habitually +conjugate, the lowest in the scale of development as well as the +highest, and how the fertilised egg becomes the embryo which is +hatched by the mother or born of her. As the child grows older and +understands more and more of these natural processes an opportunity +can be used to make the presentation of the subject more personal. He +can be told that during childhood his own sexual processes have been +undeveloped, but that as he grows older they will awake. That with +their awakening in adolescence new temptations to self-indulgence in +thought or action may assail him, but that these temptations are +delayed by the wisdom of Nature until his understanding has grown and +his man's strength of character has developed. A high ideal of purity +should be set before boy and girl alike, and the conception of sex +from the beginning should be associated in their minds with the high +purpose to which some day it may be put. Before the boy goes to a +boarding-school he should have imbibed from his father the desire for +moral cleanliness, the knowledge of good and of evil, and a cordial +dislike for everything that is sensual, self-indulgent, or nasty. +Talks on such subjects should be very infrequent, but I believe that, +if "depolarisation" is to be achieved, they must be repeated every now +and then during later childhood and in adolescence. To attempt to +impart all this interesting information in a single constrained and +awkward interview is to court failure, or at least to run the risk +that the explanation is not fully understood, so that the child is +mystified, or even offended in his sense of propriety. + +I have dwelt at some length upon this question of sex education, +because it is one of especial difficulty when we have to deal with a +child of nervous inheritance, or with a child in whom symptoms of +neurosis have developed in a faulty home environment. Misconduct in +sexual matters is a sign of deficient nervous and moral control, and +when the conduct in other respects is ill-regulated, the development +of sexual processes must be watched with some anxiety. There are those +who see a still more intimate relationship between errors of conduct +or symptoms of neurosis in childhood and the sexual instincts. + +It is perhaps necessary here briefly to refer to the teaching of +Sigmund Freud of Vienna, because his views have attracted a great deal +of attention in this country and have become familiar to a great part +of the reading public. Freud believes that the origin of many abnormal +mental states and of the disturbances of conduct which are dependent +upon them is to be traced back to forgotten experiences, the +recollection of which has faded from the conscious mind, but which are +still capable of exerting an indirect influence. He regards the +process of forgetting, not as merely a passive fading of mental +impressions, but as an active process of repression, by which the +experience, and especially the unpleasant experience, is thrust and +kept out of consciousness. There thus arises a mental conflict between +the forces of repression and the forces which tend to obtrude the +recollection into consciousness, and at times the energy engendered in +this conflict escapes from the censorship of the repressing forces and +finds vent in the production of abnormal mental states or disorders of +conduct. Thus to take a simple example, a business man who has had a +trying day at the office, on returning home in the evening may succeed +in thrusting out of his consciousness the thought of his +disappointments and worries, yet the disturbance in his mind may show +itself in quarrels with his wife or complaints of the quality of the +cooking at dinner. + +Freud has called attention to the part which the suppressed and +long-forgotten experiences of early childhood play in the production +of neuroses of all sorts at a later date, and he has laid especial +emphasis on sexual experiences as peculiarly fruitful causes of such +disturbances. Those who have embraced Freud's teaching have gone even +farther than he in this direction, and by psycho-analysis--that is to +say, by attempting in intimate conversation to arouse the dormant +memory and lay bare the buried complex, the suppression of which has +produced the conflict in the mind of the sufferer--will seldom fail to +discover the influence of sexual forces and sexual attractions which, +while capable of causing disorders of mind and of conduct, show +themselves only obscurely and indirectly, as, for example, in dreams +or in symbolic form. + +So far as the nervous disorders of children are concerned, much that +is written to-day upon the influence of repressed sexual experiences +may be dismissed as grotesque and untrue. The conclusions to which the +psycho-analyst is habitually led, and which he puts forward with such +confidence, can be convincing only to those who have replaced the +study of childhood by the study of the writings of Freud and his +school. Thus it is common enough to find a mother complaining that her +child of two or three years of age is bitterly jealous of the new baby +who has come to share with him his mother's love and attention. +According to the views of Freud, we are to recognise in this jealousy +an exhibition of the sexual instincts of the older child, who scents a +possible rival for the affections of his mother. Even if we give to +the term sexual the widest possible meaning, it is difficult for a +close observer of children to detect any truth in this conclusion. The +behaviour of the older child to the newly born will be determined +mainly by the attitude adopted by the grown-up persons around him and +by the unconscious suggestions which his impressionable mind receives +from them. If the mother is fearful of what may happen, and refuses to +leave the children alone, she will find it hard to hide from the older +child her conviction that danger is to be apprehended from him. If +this suggestion acts upon his mind, and if the reputation that he is +jealous of the new baby becomes attached to him, he will assuredly not +fail to act up to it, and her daily conduct will appear to prove the +justness of his mother's apprehension. Fortunately, mothers are +commonly able to divest themselves of such fears as these. The older +child is brought freely to the baby to admire him, to bestow caresses +on him, and to speak to him in the very tones of his elders. In a few +days his reputation is established, that he is "so fond of the baby," +and to this reputation too he faithfully conforms. We have seen in an +earlier chapter that constantly and ostentatiously to oppose a child's +will is to produce a counter-opposition which because of its +persistence and vigour appears to have behind it the strongest +possible concentration of mind and power of will. Yet if we cease to +oppose, the counter-opposition which appeared so formidable at once +dissolves, and the difficulty is at an end. We took as an example the +child's apparent determination to approach as near as possible to the +fire, the one place in the room which our fear of accident forbids +him. The difficulty with the new baby is but another example of the +same tendency. If he does not know that the ground is forbidden, if we +do not concentrate his attention on the prohibition, he will show no +particular desire to approach it. His apparent jealousy of his little +brother is the result not of the rivalry of sex, but of bad +management. + +Again, it is occasionally a subject of complaint that children will +apparently dislike their father, that they will shrink from him or +burst into tears whenever he approaches them. There is no need to see +in this the child's jealousy of the father as a rival in the +affections of his mother, which is the explanation proffered by the +school of Freud. Every action and every occupation of the child during +the whole day can be made a pleasure or a pain to him, according to +the attitude of his nurse and mother towards it. Eating and drinking +should be pleasant and are normally pleasant. The same forces which +are sufficient to make every meal-time a signal for struggling and +tears, are sufficient to produce this dislike, apparently so +invincible, to the father of his being. + +Although the nervous troubles of infancy are not commonly due, as +Freud and his numerous followers would have us believe, to suppressed +sexual desires or experiences, it is clear that in the sensitive mind +of the child the reception of a severe shock may have effects long +after the memory of it has disappeared from consciousness. In a +medical journal there was recently recounted the case of an officer of +the R.A.M.C. who all his life had suffered from claustrophobia--the +fear of being shut up in a closed space. By skilful questioning, the +remembrance of a terrifying incident in his childhood was regained. As +a child of five he had been shut in a passage in a strange house by +the accidental banging to of a door, unable to escape from the +attentions of a growling dog. A complete cure was said to follow upon +the discovery that in this incident lay the origin of the phobia. +Nevertheless, observation would lead me to lay the greater stress not +upon any one particular shocking or terrifying experience, but upon +the attitude of parents and nurses in focusing the child's attention +upon the danger, and in sapping his confidence by showing their own +apprehensions and communicating them to him. + +As a method of treatment for neuroses of childhood, psycho-analysis is +not only unsuccessful, it has dangers and produces ill effects which +far outweigh any advantage which may be gained from it. + +There can be no doubt that Freud has exaggerated the part which sexual +impulses play in causing neurosis. It will be sufficient for us to +recognise that for the nervous child the sexual life has especial +dangers, and we should redouble our efforts to prevent his ideas on +the subject becoming "polarised." For the child whose environment has +been well regulated and who has developed strength of character, +self-control, and self-respect, there need be no fear. + + + + +CHAPTER XIV + +THE NERVOUS CHILD AND SCHOOL + + +At the onset of puberty childhood comes to an end, and the period of +adolescence begins. Into these further stages of development it is not +proposed to enter, but it may be well to consider a question which is +apt to present itself for answer at this period: "Should the boy, or +girl, of nervous temperament, or whose development up to this point +has been accompanied by symptoms of nervous disorder, be sent to a +boarding-school?" So long as the child remains at home the home +environment is the force which alone is concerned in moulding his +character. We have seen how plastic the young child is, how imitative, +how suggestible, how prone to form habits good or bad. The diversity +of type shown by the homes is reflected in the diversity of character +and conduct exhibited by the children. The home is the culture medium, +and in no two homes is its composition the same. For each child home +influence remains to a great extent unchanged, and in great part +unchangeable. Its action upon the child is constant and long +sustained. Hence, it is not surprising that the growth of his +character and powers is commonly unequal. At one point we may find a +good crop of virtues, at another a barren tract; and the home +influences which have ripened the one and blighted the other are +calculated by the lapse of time to increase the contrast rather than +to diminish it. + +I suppose it is for this reason that the custom of sending children to +boarding-schools has so firm a hold among us. The boarding-school +forms an environment selected to correct the inequalities which result +from the special action upon the child of individual homes. The life +of a boy in one of our large public schools is well calculated to act +as a corrective in this way not only by reason of its ordered routine +and discipline, but still more because it is affected, perhaps for the +first time, by the strong force of public opinion. It is the strength +of this public opinion which gives to our public schools their +peculiar character and produces their peculiar effects. That which the +schoolboy most despises is what he calls "Bad Form," and he bows down +and worships an idol he himself has set up, the name of which is "Good +Form." Public opinion forms the code of morals observed in the school. +The standard set is commonly not so high as to be very difficult of +attainment. It demands many good qualities. To lie, to sneak, to tell +tales, to bully, to "put on side," are bad form. In some respects the +definition of what is virtuous may be a little hazy. Thus it may be +wrong to cheat to gain a prize, but to copy from one's neighbour only +so much as will enable one to pass muster and escape condemnation is +no great sin. In short, good form demands that a boy should have all +the social virtues: that he should be a good fellow, easy to live +with, and possessed of a high sense of public spirit--good qualities +certainly, though perhaps not those which help to make the reformers +or martyrs of this world. + +The school life is the life of the herd, and to be successful in it +the boy must mingle with the herd, not break from it or shun it. Good +form--if we came to analyse the conception that underlies it--consists +only in a close approximation to the standard pattern; bad form, in +any deviation from it. It is this similarity of type and community of +ideals which makes it so easy for most public-school boys to get on +well with one another. When in after life they are thrown among a set +of men who know nothing of their conception of good form, and whose +training has been on completely different lines, there may be a +corresponding difficulty. + +Now what is true of public-school life is of course also true of the +larger life after schooldays are over for which all education is a +preparation. These qualities of sociability and good sportsmanship +will stand a man in good stead throughout life. Even the most ardent +and active spirit will benefit by being subjected for some years to +this steady pressure of public opinion. The most part will learn from +it good sense, consideration for others, and self-control. As they +pass from the lower forms to the higher in the school they will learn +too to support authority without doing injustice, and to bring the +weight of public opinion to bear upon others. And to all this +training many a man owes his happiness in after life--a happiness +which he could not have secured if his character had been moulded only +by the environment of his home, or by the home in combination with the +less-powerful corrective of a day school. For the nervous child the +passage from home to school life may involve considerable mental +strain. He may be morbidly self-conscious and timid, or, unknown to +himself--because he has as yet no power of self-analysis and has no +opportunities of comparing himself with others--he may have developed +certain eccentricities. In most cases the plunge into school life will +be taken well enough; in a few the little vessel will not right +itself, and proves permanently unseaworthy. No doubt as a rule a +private school will have preceded the public school, and this +gradation should make the entrance to the public school a lesser +ordeal. But it often happens that it is just in the case of the +nervous child that this intermediate stage has been omitted, and that +his thirteenth birthday finds him still in the home circle. + +If the boy's father has first-hand knowledge of life in the lower +forms of public schools, his experience may enable him to form some +estimate of the effect of school life upon the nervous system of his +son. It is when parents or guardians have no such experience of their +own to guide them that mistakes are most liable to be made. I can +myself remember the unhappy state of some solitary and eccentric +schoolfellows of mine who aroused the resentment of "the Herd" by +their behaviour or opinions. If it is clear that the boy has a +peculiar temperament and is likely to suffer in this way, some _via +media_ must be found. The home has failed so that he must leave home +and come under the influence of some one who understands the nature of +the difficulty and can adapt the boy to school life. A change of +environment of this sort as a preliminary to the public school is +often all that is needed. If his age permits, every effort should be +made in this way to obtain for the nervous child who has developed +peculiarities or faults the benefits of a public-school education. + +Some types of nervous children will show immediate improvement when +they go to school. The boy who is passionate and disobedient, and +whose parents cannot control him, is best at school. Boys who, from +being much with grown-up people, have become too precocious and have +acquired the habits and tastes of their elders, will dislike school at +first, but it will do them good. Their fault shows that they are quick +to learn and sensitive to the influences of others, and they will soon +adapt themselves to their new surroundings. Boys who are dreamy and +imaginative, who early adopt a "specialist" attitude towards life, +who, however ignorant they may be of everything else, cultivate a +reputation for omniscience in some particular subject, such as +Egyptology, astronomy, or the construction of battleships, are usually +nervous boys whose symptoms will disappear at school. Where undue +timidity, phobia, or habit spasm is present, the question is more +difficult to decide. Every individual case must be studied as a whole, +and our object should be not unnecessarily to deprive the boy of the +wholesome training of public-school life. + +There are parents who from sheer ignorance add to the difficulties +which the boy encounters in going to school. Failure to appreciate +very small points may cause unnecessary suffering. To be the only boy +in the school to wear combinations is not a distinction that any new +boy craves, however strong his nerves may be. A friend of mine still +relates with feeling how, twenty years ago, he arrived at school with +shirts which _buttoned_ at the neck! At night when every one else in +the dormitory was asleep he sat for hours on his bed, miserable beyond +words, removing the buttons and doing his best in the dark to bore +buttonholes which would admit what every other boy in the school +had--a collar stud. + +With girls perhaps this question of fitness for school life does not +arise in so urgent a way. Girls are usually older when they go to +school, and girls' schools are perhaps less terrifying and more like +home. There is, however, one important point which should be borne in +mind. The date of the onset of puberty varies much in both sexes. If +the boy grows to a great hulking fellow at fourteen, and even displays +a desire secretly to borrow his father's razor, he is at no particular +disadvantage as compared with his fellows. He is so much bigger and +stronger than the others that he may thereby early enjoy the +distinction of playing at "big side," or of getting a place in the +school Eleven. He is probably much envied by those of the same age +who, with the aid of their youthful aspect, can still occasionally +extract compensation by inducing the railway company to let them +travel to school at half fare. But with girls it is different. Many at +fourteen or fifteen are children still; some are grown up, with the +tastes, feelings, and attraction of maturity. Those who have developed +fastest are often, for that very reason, kept backward in school +learning. Often they are nervously the least stable. Now that large +schools for girls on the model of our public schools are become the +fashion, such precociously developed and nervously unstable girls are +apt to find themselves in the very uncongenial society of little girls +of twelve or thirteen. The elder girls commonly hold aloof, while +mistresses are apt to view this precocious development with +disapproval, and to attempt to retard what cannot be retarded by +insisting that the young woman has remained a child. I remember being +called in consultation by a surgeon who had been asked to operate for +appendicitis upon a girl of fourteen. I found a tall, well-grown girl, +with an appearance and manner that made her look four years older. I +could find no signs of appendicitis, but I learned from her that she +had been for three months at a large girls' school, and that in a few +days' time her second term was due to begin. As we became friends, she +agreed that her appendicitis and her resolve not to return to school, +where she was unhappy, were but different ways of saying the same +thing. She was an only child who had travelled a great deal with her +parents, had found her interests in their pursuits, and had grown +backward in school work. The little girls with whom she was expected +to associate seemed to her mere children. The elder girls did not want +her friendship, and snubbed her. I prescribed a change to a small +boarding-school with only a few girls, where age differences would not +matter so much, and where she could make friends with girls older than +herself, though not more mature. + +Into their school life we need not follow the children. Happily the +time is past when schoolmasters and schoolmistresses were incapable of +understanding their charges, and confounded nervous exhaustion with +stupidity or timidity with incapacity. + +And so we come back to the point from which we started: + +The nervous infant, restless, wriggling, and constantly crying! The +nervous child, unstable, suggestible, passionate, and full of nameless +fears! The nervous schoolboy or schoolgirl prone to self-analysis, +subject-conscious, and easily exhausted! And how many and how various +are the manifestations of this temperament! Refusal of food, refusal +of sleep, negativism, irritability, and violent fits of temper, +vomiting, diarrhoea, morbid flushing and blushing, habit spasms, +phobias--all controlled not by reproof or by medicine, but by good +management and a clear understanding of their nature. + +The hygiene of the child's mind is as important as the hygiene of his +body, and both are studies proper for the doctor. Neuropathy and an +unsound, nervous organisation are often enough legacies from the +nervous disorders of childhood. + + + + +INDEX + + +Abdomen, prominent + +Abdominal symptoms of neurosis + +Accent, local, facility with which acquired + +Acetone, in breath and urine during cyclic vomiting + +Acidosis, accompanying cyclic vomiting + +Action, imitativeness of + liberty of, in early childhood + +Activities in the nursery + not to be restrained + without intervention of grown-up people + wonderful nature of + +Adenoid vegetations, night-terrors aggravated by + removal of, in treatment of enuresis + +Adolescence, and education on sexual matters + +Adults, child in relation to the society of + +Æsthetic sense, in early childhood + +Affection, in the child + +Air hunger, in cyclic vomiting + +Air swallowing, habitual action of + +Albuminuria, associated with faulty posture + cause of, in neuropaths + +Allimentary disturbances, symptom of + +Alkali, in treatment of cyclic vomiting + +Anæmia, of neuropaths + +Anorexia nervosa + A case illustrating + +Apnoea, fatal cases of + following burst of crying + twitching of facial muscles in + +Appetite, emotional states affecting + loss of, + case illustrating + causes and characteristics + treatment + means of stimulating + nature of the sensation of + +Apprehension, causes of + growth of neuroses in atmosphere of + +Artificial feeding + +Aspirin + +Asthma, treatment of + +Attention, child's love of attracting + examples of + +Authority, delight in defying + over-exercise of, by parents, results of + + +Babies. _See_ Newborn Baby + +Backward development + signs of + +"Bad form" + +Bad habits + +Bath, baby's first experience of + +Bed, dislike of + how overcome + efforts to resist preparation for + +Bedroom, airing and temperature of + +Bedtime + management at + +Bed wetting. _See_ Enuresis + +Behaviour. _See_ Conduct + +Bladder, hydrostatic distension of, for enuresis + +Boarding-schools, object of + +Bodily ailments, and instability of nervous control, connection between + _See also_ Disorders + +Body, + and mind, development of + development of + environment influencing + effect of mind on + gradual alterations in the shape of + infantile characteristics in later childhood + +Bone, and muscle, changes in, in infantile children + +Books, + child's attitude towards + educative value of + kinds most suitable + +Brachial nerve, pressure causing tetany + +Breast-feeding, + best time for + causes of failure in + observations on + _See also_ Lactation + +Breath-holding + action during + fatal cases of + phenomena of + +Bromides, administration of + to newborn baby + + +Cajoling, futility of + +Calcium bromide, in treatment of spasms + +Calcium metabolism, disturbance of + +Care, ill effects of excess of + +Carpo-pedal spasm + +Catarrhal infections + connection of rheumatism with, 155 + +Cerebral anæmia + +Cerebral circulation, stagnation of + +Cerebral exhaustion. _See_ Mental Exhaustion + +Cerebral functions, + rapid growth of + unstable in the child + _See also_ Mental + +Character, + formation of + during school life + home influence in the development of + ideals of, how inculcated + +Children's parties, disadvantages of + +Chloral, administration of + to newborn baby + in treatment of spasms + +Chorea, + and rheumatism, association between + symptom of cerebral irritability + treatment of + +Chvostek's sign, characteristics and nature of + +Circulation, cerebral, + stagnation of + nervous control of + +Claustrophobia + +Clothing, + kind suitable + new, child's delight in + +Coaxing, + futility of + +Cold douches, improving vasomotor tone + +Coldness of extremities + +Conduct, + control of, factors in + errors of, and sexual instincts + control of + correction of + due to faults of management + in neuropathic children + excessive introspection influencing + ideals of, how inculcated + influence of environment on + influenced by suggestion + mother's influence on + of neuropaths + perverse + suggestion in the control of + +Constipation, + mental causes of + negativism in + perversion of suggestion a common cause of + suggestion in relation to + +Constitution, delicacy of + +Convulsions, fatal cases of + generalised + +Convulsive disorders + +Cough, nervous + +Counter-opposition, child's opposition growing with + +Crying, constant + formation of habit of + in emotional and excitable children + management of + mechanism of + phenomena of + purposeful + +Cyclic or periodic vomiting. _See_ Vomiting + + +Day-dreams, indicating nervous temperament + +Deceit + +Defæcation, inhibition of + painful + +Delicacy of constitution + +Delirium, tendency to + +Depolarisation of ideas + +Depression, recurrence of periods of + +Dexterity, lack of + manual, advantages of + toys developing + +Diaphragm, spasm of + +Diarrhoea, mucous + +Diet, likes and dislikes for articles of + opposition to + of newborn child, changes in + _See also_ Food + +Digestion, emotional states affecting + +Digestive disorders, mental causes of + +Digestive neuroses + +Digestive system, symptoms of extreme sensibility of + +Dirt eating + +Discipline + in later childhood + in the school + misdirected efforts at enforcing + severe, effects of + +Dishonesty + +Disobedience, + growth of + habit of + personality and + perverse attitude of + reproof and coaxing causing + +Disorders, ætiology of + associated with neurosis + common + environment as cause and cure of + of neuropaths + treatment of + trifling + +Diuresis, excessive + +Doll, child's care of, an example of imitativeness + educative value of + +Douches, cold, improving vasomotor tone + +Dover's powder + +Dreams, + nature of, indicating nature of mental unrest + +Drugs, in sleeplessness + +Ductless glands, in relation to infantile characteristics + +Dullards + +Dyspepsia, complications of + course and effects of + mental aspects of + nervous symptoms of + symptoms in newborn infant + treatment + + +Early childhood, care during + impulse of opposition in + love of power in + +Early childhood, nervousness in + reasoning power in + three common neuroses of + toys, books, and amusements in + _See also_ Newborn Baby + +Education, aim of + by games and toys + on sexual matters + +Educative value, of books, games, and toys + +Emotional states, appetite affected by + causing spasm + management of + of neurotics, exaggeration of + physical disturbances due to + producing laryngismus stridulus + +Emotional storms + +Endocrine glands + +Enuresis, + causal factors in + characteristics and peculiarities of + condition of urine during + mental aspects of + mistakes in treatment of + perversion of suggestion as cause of + removal of tonsils in + treatment, essentials in + hypnotic suggestion in + methods of + +Environment, body moulded and shaped by + change of, beneficial effects of + effect in developing child's powers + effect on common disorders + errors of, and neuropathic children + essentials of + faulty contact with, in neuropathic children + for neuropaths + influence on conduct in later childhood + influence on mental processes + influence on personality + irritating nature of the adult mind in + of the home, reflected in the child + of school life + stimulus of + susceptibility to influences of + +Epilepsy, cyclical character of + +Evil, inborn disposition to + +Excitable children, management of + +Exercise, sleep in relation to + +Exhaustion. _See_ Mental Exhaustion + +Expostulation, frequent, bad effects of + _See also_ Reproof + +Expressions, to attract attention + + +Facial muscles, twitching of + associated with apnoea + +Fæces, incontinence of + +Fainting fits, + cause and characteristics + control of + of neuropaths + +Fatigue, mental, physical, and visceral + +Fats, lowered tolerance to + +Faults, correction of + not corrected by too frequent reproof + +Fear, + causes of + phenomena of + prominent psychical symptom of neuropathic children + treatment of + +Feeding, + artificial + factors in + of newborn infant, regularity in + +Fertilisation, method of imparting knowledge of + +Food, force of suggestion in relation to + healthy desire for + likes and dislikes for + how overcome + phenomena of the desire of + refusal of + nervous causes of + persistent, factors encouraging + suggestion in relation to + treatment of + +Force and cajoling, futility of + +Freud, teaching of + +Functional disturbances, in combination with organic disease + + +Gait, peculiarity of + +Games, educative value of + +Gastric disturbances + +Gastric juice, psychic secretion of + +Gastric symptoms, of neurosis + +Gastro-intestinal derangement, causes of + environment as cause and cure of + +Gentleness, + inculcation of + +Girls' schools + +Glottis, spasm of, strong emotion causing + +"Good form" + +Grasping habit, reproof in relation to + +Growing pains + + +Habit spasms, age of appearance of + cause of + definition of + examples of + spread of + suggestion in relation to + treatment of + +Habits, regulation of + suggestion in relation to + +Habitual actions, infant's pleasure in + mental unrest in relation to + of the parent, reproduction in the child + varieties and characteristics + +Habitual wakefulness + +Hands, control of movement of + expressionless + +Happiness and contentment, of child when playing alone + +Headache, periodic. _See_ Migraine + +Heat and cold, newborn baby in relation to + +Heat and flushing, sudden sensations of + +Heredity, and temperament + and type of child + nervous disorders in relation to + +Home influence, in development of character + reflected in the child + +Hunger, of the newborn baby + +Hypnotic suggestion, in treatment of enuresis + +Hypnotics + +Hysteria, + age of appearance of + suggestion in relation to + symptoms of + +Hysterical girls, characteristics of + + +Ideals, inculcation of + +Ideas, polarisation and depolarisation of + +Illness. _See_ Sickness + +Imagination, abnormal, correction of + child's stories and tales in relation to + developed by toys + +Imitativeness, age at which apparent + extent of + illustration of + lack of + of action + of speech + tell-tale child an illustration of + +Incontinence of urine + +Incorrigible children + +Infantile characteristics, + ductless glands in relation to + nervous system in relation to + +Infective disorders, + convalescence from + producing nervous symptoms + relation of neurosis to + +Inflammatory reactions + +Insomnia. _See_ Sleeplessness + +Intellect, compared with physique + +Intelligence, in early childhood + +Intestinal disturbance + of neurosis + symptom of + +Intoxications, violent reaction to + +Introspection, and neuropathic children + excessive, evidences of + influencing conduct + +Irritation, child to be free from + + +Joint pains + + +Kindergarten school, artificial symbolism of + +Kindness, inculcation of + + +Lactation, + care of child during + care of mother during + causes of failure in + establishment of + tongue-tie in relation to + +Laryngismus stridulus. _See_ Breath-holding + +Later childhood, + infantile characteristics in + management in + mental backwardness in + +Likes and dislikes + +Lordosis + and neurosis + producing albuminuria + + +Manual dexterity, advantages of + +Massage, improving tone of muscles + +Medicines, sensitiveness to + +Melancholy children + +Mental aspects, of digestive disorders + of enuresis + of management in early childhood + +Mental backwardness, + and infantile characteristics + in later childhood + +Mental disturbances, + cyclical character of + indicating neuropathic tendencies + irregularities of sleep due to + psycho-analysis of + +Mental exhaustion, + during convalescence from infective disorders + easily produced in nervous children + +Mental irritability, chorea a symptom of + +Mental life of the child + +Mental power, + active before beginning of speech + in early childhood + +Mental processes, development of + age at which most apparent + in later childhood + effect of unconscious suggestions on + heredity in relation to + influence of environment on + +Mental training + compared with physical training + objects and advantages of + +Mental unrest, + avoidance of + crying in relation to + digestive disturbances due to + growth of neuroses in atmosphere of + habitual actions in relation to + in the adult + in the child + negativism due to + of newborn infant, effects of + _See also_ Nervous Unrest + +Micturition, + functional disorder of + negativism in + regulation of + _See also_ Enuresis + +Migraine, + periodic vomiting associated with + symptom of nervous exhaustion + +Mind, + and body, development of + effect on the body + vigour of, in relation to that of body + +Money, theft of + +Montessori system of training + +Moral degeneracy + +Moral standard of school life + +Moral training + importance and effects of + negative virtues and + objects and advantages of + parents' responsibilities in + +Morals, public opinion forming code of + +Morbid introspection + +Mothers, + ability and inability to manage children + attitude in regard to temperament of child + care of, during lactation + conduct of child influenced by + inability to understand nature of child's disorders + influence of, on tone and manner of speech + mental environment of child created by + personality of + relation to the child + +Motionless children + +Mouth, habit of conveying everything to, cause of + +Movements, + precision of + purposive, development of + self-command of + +Muscular atrophy, and neurosis + +Muscular system, + changes in infantile children + weak development of + +Muscular tone, how improved + +Myopathy, primary + + +Nasal obstruction + and failure of lactation + night-terrors aggravated by + +Natural history, sexual matters taught by + +Naughtiness, child's delight in + +Naughty, use of the term + +Negative virtues, and moral training + +Negativism, + cause of + characteristics + factors developing + in constipation + in micturition + spirit of + treatment of + want of sleep depending on + +Nerve centres, controlling movement, development of + +Nervous control, instability of, connection between bodily ailments and + +Nervous cough + +Nervous disorders, + and psycho-analysis + common, causes, characteristics, and treatment + frequency of + +Nervous exhaustion, cyclic vomiting and migraine symptoms of + +Nervous instability, stigma of + +Nervous system, abnormal in children + in relation to cyclic vomiting + increased irritability of + infantile characteristics of + +Nervous unrest, environment in relation to + factors increasing + manifestations of + recurrence of periods of + symptoms of + _See also_ Mental Unrest + +Nervous vomiting. _See_ Vomiting + +Nervousness, and digestive disorders + and neuropathy + in early infancy + in older children + parents' attitude causing + +Nettlerash + +Neurasthenia + +Neuropathic children, common symptoms of + conduct of + faulty contact with environment in + fear the prominent symptom of + introspection and self-consciousness of + management of + training of + +Neuropathic tendencies, evidence of, in older children + +Neuropaths, adult + faulty management in child life leading to + phenomena of + phobias of + selection of suitable environment for + symptoms of + +Neuroses, and psycho-analysis + association of albuminuria with + constipation frequently due to + examination of + growth in atmosphere of unrest and apprehension + relation of, to infection of the body + treatment of + +Neurotics, and physique + characteristics + exaggeration of emotions of + +Newborn baby, administration of sedatives to + artificial feeding of + breast feeding of + case of + effect of mental unrest on + first impressions of + formation of habits of sleep and crying in + heat and cold in relation to + hunger of + induction of the sucking movements of + of nervous inheritance + personality of + prevention of restlessness and crying + reduction of sense stimuli in + reflex action of sucking in + sense of taste of + symptoms of dyspepsia in + times of feeding + weaning of + +Night-terrors, aggravation of, + causes of + of neuropathic children + +Nursery, activities in, child's interest in + importance of child's being alone in + observations in + +Nursery life, advantages of + +Nursery psycho-therapeutics + +Nurses, ability and inability to manage children + influence of, on tone and manner of speech + mental environment of child created by + personality of + +Nursing, during sickness + of the newborn infant + + +Obedience + and perverse pleasure + growth of + +Obsession of bed wetting + +Opposition + and counter-opposition + during sickness + force of, factors influencing development + habit of + impulse of + love of, in early childhood + to food + +Organic disturbance, in combination with functional trouble + + +Pain, frequent loss of sense of, in neuropaths + +Pallor + sudden attacks of + +Palpitation, example of visceral fatigue + +Parathyroid glands, function of + +Parents, + and children, conflict between + and silence on sexual matters + habitual actions of, reproduced in the child + mental attitude of, in relation to conduct + over-exercise of authority by, results of + responsibilities in moral training of child + suggestions unconsciously conveyed by, evil results of + +Parties, disadvantages of + +Patient, temperament of, physician in relation to + +Pelvis, development of + +Peripheral nerves, increase in irritability and conductivity of + +Personal adornment, delight in + +Personality, + and disobedience + child's own conception of + environment influencing + in early childhood + of newborn baby + +Perspiration, abundant, sudden attacks of, 141 + +Phobias, + characteristics and varieties + frequency of + treatment of + +Physical defects, accompanying neurosis + +Physical disturbances, due to emotion + +Physical exercise, lack of, causing want of sleep + +Physical fatigue, easily produced in nervous children + +Physical phenomena of neuropaths + +Physical training, + objects and advantages of + +Physician, + and the temperament of his patient + examination by + diagnosis by + difficulties of + +Physique, intellect compared with + +Pica and dirt eating + +Picture books, + educative value of + kinds most suitable + +Play, + happiness of child during + in the nursery + with grown-up persons + +Pleasure, sense of, in early childhood + +Polarisation of ideas + +Postural albuminuria + +Posture, faulty + prevention of + +Power, child's love of + +Precision of movement, development of + +Psycho-analysis, + dangers of + observations on + +Public schools, character and effects of + +Punishment, + deserved and undeserved + frequent, disadvantages of + observations on + +Purity, inculcation of high ideals of, + +Purposive movements, earliest, + cause of + encouragement of + +Pyloric spasm + +Pyrexia, + organic disease in relation to + + +Rational hygiene + +Reasoning power, + active before advent of speech + factors influencing development of + +Regulation of habits + +Repression, by older children of younger + +Reproduction, method of imparting knowledge of + +Reproof, + cases in which useless + causing disobedience + effects of + extreme sensitiveness to + perverse pleasure of + too frequent repetition of, futility of + +Restlessness, during sickness + +Rewards, use and dangers of + +Rheumatism, + and chorea, association between + characteristics in childhood + subacute + treatment of + +Rickets, + mental and intellectual condition in + in infantile children + occurrence with spasmophilia + +Right and wrong, appreciation of, in early childhood + +Round shoulders + + +St. Vitus's dance + +Salts, excretion of + +School life, + and sexual matters + moral standard of + moral training and + moulding of character during + of boys + of girls + +Schools, public, character and effects of + +Scoliosis, prevention of + +Secretions, anomalies of + +Self, child's conception of + +Self-conscious children, complaints of + +Self-consciousness, of neuropathic children + +Self-discipline, development of + +Self-education, in the nursery + +Self-feeding + +Self-preservation, morbid instinct of + +Self-sacrifice, not to be expected in early childhood + +Sensations, + acuteness of + bodily, of neuropaths + +Sense perception, of neuropaths + +Sense stimuli, + cultivation of perception of + in newborn babies + +Sexual matters, + education on + method of + errors of conduct and + parents' silence in regard to + psycho-analysis in relation to + school life in relation to + +Sickness + evil effects of suggestions unconsciously conveyed by parents during + management during + nurse and mother during + opposition during + temperature during + therapeutic measures in + therapeutic procedures concentrating child's mind on his symptoms + +Sleep, estimation of the amount of + force of suggestion in relation to + formation of habit of + light and broken, cause of + of newborn infant + sound, beneficial effects of + +Sleeping attire + +Sleeplessness, breaking of the habit of + causes and characteristics + drugs in + in older children + lack of physical exercise causing + suggestion in relation to + treatment of + +Sleep-walking + +Snatching, habit of + +Spasmophilia + ætiology of + drugs in treatment of + occurrence of rickets with + +Spasms, control of + fatal + +Speech, beginnings of + facility with which local accent is acquired + imitativeness of + infant's reasoning power present before advent of + influence of nurses and mothers on tone and manner of + +Spinal deformity, prevention of + +Spinal muscles, atrophy of + +Spoon feeding + +Status catarrhalis + +Status lymphaticus + +Story-telling + +Sucking movements, of newborn child, induction of + _see also_ Lactation + +Suggestion, and habit spasms + appetite in relation to + bed wetting in relation to + bodily habits in relation to + characteristics + conduct influenced by + constipation in relation to + effect on mental processes + food in relation to + force of, on child's mind + hysteria in relation to + perverse influence of + bad habits due to + causing constipation + want of sleep depending upon + refusal of food in relation to + sleep in relation to + susceptibility to + unconsciously conveyed by parents, evil results of + +Suicide + +Suspicions, aroused in the child + +Syncopal attacks, causes and characteristics + + +Tactile sensation. _See_ Touch + +Taste, perversion of + sensations of + how controlled + sense of, in newborn infant + +Teething convulsions + +Tell-tale child, characteristics + +Temperament, diversity of + heredity and + mother's attitude in relation to + of the patient, physician in relation to + +Temperature, during sickness + inexplicable rises in + +Terror, causes, of + +Tetany, liability to, in increased irritability of nervous system + pressure to brachial nerve causing + +Theatres, disadvantages of + +Theft + +Therapeutic conversation + +Thigh rubbing, + avoidance of + characteristics + habitual action of + +Thorax, development of + +Thumb sucking + persistence of the habit + +Tongue-tie, in relation to lactation + +Tonics + +Tonsils, removal of, in treatment of enuresis + +Touch, sense of, + cultivation of + early development of + organs with greatest development of + +Toys, + child's interest in + educative value of + kind most suitable + +Training, early, importance and object of + +Trousseau's sign, nature and production of + +Truthfulness + inculcation of + +Twitching of facial muscles + +Tyranny of tears + + +Unkindness, habitual, of children to others + +Untruthfulness + over-exercise of authority encouraging + +Urine, + condition in enuresis + incontinence of, methods of treatment + _See also_ Enuresis + increased secretion of + irritation of + + +Vasomotor instability + conditions indicating + in neuropaths + +Vasomotor tone, how improved + +Virtuous, definition of the term + +Visceral fatigue, easily produced in nervous children + +Vocabulary + +Voice, tone of + +Voluntary movements, development of cerebral centres controlling + +Vomiting, cyclic + ætiology of + age at which it occurs + case illustrating + causes and characteristics + class of child affected by + condition of the child during + frequency of attacks + migraine in association with + nervous system in relation to + treatment of + + +Waking states + +Weaning, difficulty in + +Will, strength of, absence in childhood + +Work and play, differentiation between + +Writing, correct posture during + + + + +Transcriber's Notes + +The following typographical errors were corrected: +Page 4: 'sensisive' changed to 'sensitive'. +Page 48: 'self-abnegnatio'n changed to 'self-abnegation'. +page 61: Fixed 'and and'. +Page 125: 'acount' changed to 'account'. +First page of index (191): 'ullimentary' changed to 'Allimentary'; + also 'ilstrating' channged to 'illustrating'. + + + + + +End of Project Gutenberg's The Nervous Child, by Hector Charles Cameron + 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: The Nervous Child + +Author: Hector Charles Cameron + +Release Date: December 29, 2004 [EBook #14515] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK THE NERVOUS CHILD *** + + + + +Produced by Audrey Longhurst, Ronald Holder and the PG Online +Distributed Proofreading Team + + + + + + +</pre> + + + + + + + + +<h1>THE NERVOUS CHILD</h1> + +<p> </p> +<p> </p> + +<h4>PUBLISHED BY THE JOINT COMMITTEE OF</h4> +<h4>HENRY FROWDE, HODDER & STOUGHTON</h4> +<h4>17 WARWICK SQUARE, LONDON, E.C. 4</h4> + +<p> </p> +<p> </p> + +<h1>THE</h1> +<h1>NERVOUS CHILD</h1> + +<p> </p> + +<h3>BY</h3> + +<h2>HECTOR CHARLES CAMERON</h2> +<h4>M.A., M.D.(<span class="smcap">Cantab.</span>), F.R.C.P.(<span class="smcap">Lond.</span>)</h4> +<h4>PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF</h4> +<h4>THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL</h4> + +<p> </p> +<p> </p> + +<div class="blockquot"><p>"RESPECT the child. Be not too much his parent. Trespass not on + his solitude."—<span class="smcap">Emerson.</span></p></div> + +<p> </p> +<p> </p> + +<h3>LONDON</h3> +<h3>HENRY FROWDE HODDER & STOUGHTON</h3> +<h3><span class="smcap">Oxford University Press Warwick Square, E.C.</span></h3> +<h4>1920</h4> + +<p> </p> +<p> </p> + +<h4><i>First Edition</i> 1919</h4> +<h4><i>Second Impression</i> 1930</h4> + +<p> </p> +<p> </p> + +<h4><span class="smcap">Printed in Great Britain</span></h4> +<h4><span class="smcap">By Morrison & Gibb Ltd., Edinburgh</span></h4> + +<p> </p> +<p> </p> + +<hr style="width: 65%;" /> +<h2><a name="PREFACE" id="PREFACE" />PREFACE</h2> + +<p> </p> +<p>To-day on all sides we hear of the extreme importance of Preventive +Medicine and the great future which lies before us in this aspect of +our work. If so, it follows that the study of infancy and childhood +must rise into corresponding prominence. More and more a considerable +part of the Profession must busy itself in nurseries and in schools, +seeking to apply there the teachings of Psychology, Physiology, +Heredity, and Hygiene. To work of this kind, in some of its aspects, +this book may serve as an introduction. It deals with the influences +which mould the mentality of the child and shape his conduct. Extreme +susceptibility to these influences is the mark of the nervous child.</p> + +<p>I have to thank the Editors of <i>The Practitioner</i> and of <i>The Child</i>, +respectively, for permission to reprint the chapters which deal with +"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I +should also like to offer thanks for helpful suggestions.</p> + +<p>H.C.C.</p> + +<p><i>March</i> 1919.</p> +<p> </p> +<p> </p> + +<h3>CONTENTS</h3> + + + +<table cellspacing="0" cellpadding="4" border="0" summary="Table of Contents"> +<tr> + <th align="left">CHAP.</th> + <th> </th> + <th align="center">PAGE</th> +</tr> +<tr> + <td align="right">I.</td> + <td align="left"><span class="smcap"><a href="#Page_1">Doctors, Mothers, and Children</a></span></td> + <td align="right">1</td> +</tr> +<tr> + <td align="right">II.</td> + <td align="left"><span class="smcap"><a href="#Page_18">Observations in the Nursery</a></span></td> + <td align="right">18</td> +</tr> +<tr> + <td align="right">III.</td> + <td align="left"><span class="smcap"><a href="#Page_50">Want of Appetite and Indigestion</a></span></td> + <td align="right">50</td> +</tr> +<tr> + <td align="right">IV.</td> + <td align="left"><span class="smcap"><a href="#Page_64">Want of Sleep</a></span></td> + <td align="right">64</td> +</tr> +<tr> + <td align="right">V.</td> + <td align="left"><span class="smcap"><a href="#Page_73">Some Other Signs of Nervousness</a></span></td> + <td align="right">73</td> +</tr> +<tr> + <td align="right">VI.</td> + <td align="left"><span class="smcap"><a href="#Page_89">Enuresis</a></span></td> + <td align="right">89</td> +</tr> +<tr> + <td align="right">VII.</td> + <td align="left"><span class="smcap"><a href="#Page_96">Toys, Books, and Amusements</a></span></td> + <td align="right">96</td> +</tr> +<tr> + <td align="right">VIII.</td> + <td align="left"><span class="smcap"><a href="#Page_104">Nervousness in Early Infancy</a></span></td> + <td align="right">104</td> +</tr> +<tr> + <td align="right">IX.</td> + <td align="left"><span class="smcap"><a href="#Page_117">Management in Later Childhood</a></span></td> + <td align="right">117</td> +</tr> +<tr> + <td align="right">X.</td> + <td align="left"><span class="smcap"><a href="#Page_131">Nervousness in Older Children</a></span></td> + <td align="right">131</td> +</tr> +<tr> + <td align="right">XI.</td> + <td align="left"><span class="smcap"><a href="#Page_145">Nervousness and Physique</a></span></td> + <td align="right">145</td> +</tr> +<tr> + <td align="right">XII.</td> + <td align="left"><span class="smcap"><a href="#Page_160">The Nervous Child in Sickness</a></span></td> + <td align="right">160</td> +</tr> +<tr> + <td align="right">XIII.</td> + <td align="left"><span class="smcap"><a href="#Page_169">Nervous Children and Education on Sexual Matters</a></span></td> + <td align="right">169</td> +</tr> +<tr> + <td align="right">XIV.</td> + <td align="left"><span class="smcap"><a href="#Page_182">The Nervous Child and School</a></span></td> + <td align="right">182</td> +</tr> +<tr> + <td align="right"> </td> + <td align="left"><span class="smcap"><a href="#Page_191">Index</a></span></td> + <td align="right">191</td> +</tr> +</table> + + +<p> </p> +<hr style="width: 65%;" /> +<p> </p> + +<h2>THE NERVOUS CHILD</h2> + +<p><span class="pagenum">Page 1<a name="Page_1" id="Page_1"></a></span></p> + +<h3>CHAPTER I</h3> + +<h3>DOCTORS, MOTHERS, AND CHILDREN</h3> + + +<p>There is an old fairy story concerning a pea which a princess once +slept upon—a little offending pea, a minute disturbance, a trifling +departure from the normal which grew to the proportions of intolerable +suffering because of the too sensitive and undisciplined nervous +system of Her Royal Highness. The story, I think, does not tell us +much else concerning the princess. It does not tell us, for instance, +if she was an only child, the sole preoccupation of her parents and +nurses, surrounded by the most anxious care, reared with some +difficulty because of her extraordinary "delicacy," suffering from a +variety of illnesses which somehow always seemed to puzzle the +doctors, though some of the symptoms—the vomiting, for example, and +the high temperature—were very severe and persistent. Nor does it +tell us if later in life, but before the suffering from the pea arose, +she had been taken to consult two famous doctors, one of whom had +removed the vermiform appendix, while the other a little later had +performed an operation for "adhesions." +<span class="pagenum">Page 2<a name="Page_2" id="Page_2"></a></span> +At any rate, the story with +these later additions, which are at least in keeping with what we know +of her history, would serve to indicate the importance which attaches +to the early training of childhood. Among the children even of the +well-to-do often enough the hygiene of the mind is overlooked, and +faulty management produces restlessness, instability, and +hyper-sensitiveness, which pass insensibly into neuropathy in adult +life.</p> + +<p>To prevent so distressing a result is our aim in the training of +children. No doubt the matter concerns in the first place parents and +nurses, school masters and mistresses, as well as medical men. Yet +because of the certainty that physical disturbances of one sort or +another will follow upon nervous unrest, it will seldom happen that +medical advice will not be sought sooner or later; and if the +physician is to intervene with success, he must be prepared with +knowledge of many sorts. He must be prepared to make a thorough and +complete physical examination, sufficient to exclude the presence of +organic disease. If no organic disease is found, he must explore the +whole environment of the child, and seek to determine whether the +exciting cause is to be found in the reaction of the child to some +form of faulty management.</p> + +<p>For example, a child of two or three years of age may be brought to +the doctor with the complaint that defæcation is painful, and that +there has existed for some time a most distressing constipation which +has resisted a large number of purgatives of increasing strength. +Whenever the child is placed upon the +<span class="pagenum">Page 3<a name="Page_3" id="Page_3"></a></span> +stool, his crying at once +begins, and no attempts to soothe or console him have been successful. +It is not sufficient for the doctor in such a case to make an +examination which convinces him that there is no fissure at the anus +and no fistula or thrombosed pile, and to confine himself to saying +that he can find nothing the matter. The crying and refusal to go to +stool will continue after the visit as before, and the mother will be +apt to conclude that her doctor, though she has the greatest +confidence in him for the ailments of grown-up persons, is unskilled +in, or at least not interested in, the diseases of little children. +If, on the other hand, the doctor pursues his inquiries into the +management of the child in the home, and if, for example, he finds +that the crying and resistance is not confined to going to stool, but +also takes place when the child is put to bed, and very often at +meal-times as well, then it will be safe for him to conclude that all +the symptoms are due to the same cause—a sort of "negativism" which +is apt to appear in all children who are directed and urged too much, +and whose parents are not careful to hide from them the anxiety and +distress which their conduct occasions.</p> + +<p>If this diagnosis is made, then a full and clear explanation should be +given to the mother, or at any rate to such mothers—and fortunately +they are in the majority—who are capable of appreciating the point of +psychology involved, and of correcting the management of the child so +as to overcome the negativism. To attempt treatment by prescribing +drugs, or in any other way than by correcting the +<span class="pagenum">Page 4<a name="Page_4" id="Page_4"></a></span> +faulty management, +is to court failure. As Charcot has said, in functional disorders it +is not so much the prescription which matters as the prescriber.</p> + +<p>But the task of the doctor is often one of even greater difficulty. +Often enough there will be a combination of organic disturbance with +functional trouble. For example, a girl of eighteen years old suffered +from a pain in the left arm which has persisted on and off since the +olecranon had been fractured when she was two years of age. She was +the youngest of a large family, and had never been separated for a day +from the care and apprehensions of her mother. The joint was stiff, +and there was considerable deformity. The pain always increased when +she was tired or unhappy. Again, a girl had some slight cystitis with +frequent micturition, and this passed by slow degrees into a purely +functional irritability of the bladder, which called for micturition +at frequent intervals both by day and night. In such cases treatment +must endeavour to control both factors—the local organic disturbance +must if possible be removed, and the faults of management corrected.</p> + +<p>It is a good physician who can appreciate and estimate accurately the +temperament of his patient, and the need for this insight is nowhere +greater than in dealing with the disorders of childhood. It can be +acquired only by long practice and familiarity with children. In the +hospital wards we shall learn much that is essential, but we shall not +learn this. The child, who is so sensitive to his environment, shows +but little that is +<span class="pagenum">Page 5<a name="Page_5" id="Page_5"></a></span> +characteristic when admitted to an institution. +Only in the nursery can we learn to estimate the influences which +proceed from parents and nurses of different characters and +temperaments, and the reaction which is produced by them in the child.</p> + +<p>The body of the child is moulded and shaped by the environment in +which it grows. Pure air, a rational diet, free movement, give +strength and symmetry to every part. Faults of hygiene debase the +type, although the type is determined by heredity which in the +individual is beyond our control. Mothers and nurses to-day are well +aware of the need for a rational hygiene. Mother-craft is studied +zealously and with success, and there is no lack of books to give +sound guidance and to show the mean between the dangerous extremes of +coddling and a too Spartan exposure. Yet sometimes it has seemed as if +some mothers whose care for their children's physical health is most +painstaking, who have nothing to learn on the question of diet, of +exercise, of fresh air, or of baths, who measure and weigh and record +with great minuteness, have had their attention so wholly occupied +with the care of the body that they do not appreciate the simultaneous +growth of the mind, or inquire after its welfare. Yet it is the +astounding rapidity with which the mental processes develop that forms +the distinguishing characteristic of the infancy of man. Were it not +for this rapid growth of the cerebral functions, the rearing of +children would be a matter almost as simple and uneventful as the +rearing of live stock. For most +<span class="pagenum">Page 6<a name="Page_6" id="Page_6"></a></span> +animals faults of environment must be +very pronounced to do harm by producing mental unrest and +irritability. Thus, indeed, some wild animal separated from its +fellows and kept in solitary captivity may sicken and waste, though +maintained and fed with every care. Yet if the whole conditions of +life for the animal are not profoundly altered, if the environment is +natural or approximately natural, it is as a rule necessary to care +only for its physical needs, and we need not fear that the results +will be spoiled by the reaction of the mind upon the body. But with +the child it is different; airy nurseries, big gardens, visits to the +seaside, and every advantage that money can buy cannot achieve success +if the child's mind is not at rest, if his sleep is broken, if food is +habitually refused or vomited, or if to leave him alone in the nursery +for a moment is to evoke a fit of passionate crying.</p> + +<p>The grown-up person comes eventually to be able to control this +tremendous organ, this brain, which is the predominant feature of his +race. In the child its functions are always unstable and liable to be +upset. Evidence of mental unrest or fatigue, which is only rarely met +with in grown persons and which then betokens serious disturbance of +the mind, is of comparatively common occurrence in little children. +Habit spasm, bed-wetting, sleep-walking, night terrors, and +convulsions are symptoms which are frequent enough in children, and +there is no need to be unduly alarmed at their occurrence. In adult +age they are found only +<span class="pagenum">Page 7<a name="Page_7" id="Page_7"></a></span> +among persons who must be considered as +neuropathic. To make the point clear, I have chosen examples from the +graver and more serious symptoms of nervous unrest. But it is equally +true that minor symptoms which in adults are universally recognised to +be dependent upon cerebral unrest or fatigue are of everyday +occurrence in childhood. Broken and disturbed sleep, absence of +appetite and persistent refusal of food, gastric pain and discomfort +after meals, nervous vomiting, morbid flushing and blushing, headache, +irritability and excessive emotional display, at whatever age they +occur, are indications of a mind that is not at rest. In children, as +in adults, they may be prominent although the physical surroundings of +the patient may be all that could be desired and all that wealth can +procure. It is an everyday experience that business worries and +responsibilities in men, domestic anxieties or childlessness in women, +have the power to ruin health, even in those who habitually or grossly +break none of its laws. The unstable mind of the child is so sensitive +that cerebral fatigue and irritability are produced by causes which +seem to us extraordinarily trivial. In the little life which the child +leads, a life in which the whole seems to us to be comprised in +dressing and undressing, washing, walking, eating, sleeping, and +playing, it is not easy to detect where the elements of nervous +overstrain lie. Nor is it as a rule in these things that the mischief +is to be found. It is in the personality of mother or nurse, in her +conduct to the child, in her actions and words, in the tone of +<span class="pagenum">Page 8<a name="Page_8" id="Page_8"></a></span> +her voice when she addresses him, even in the thoughts which pass through +her mind and which show themselves plainly to that marvellously acute +intuition of his, which divines what she has not spoken, that we must +seek for the disturbing element. The mental environment of the child +is created by the mother or the nurse. That is her responsibility and +her opportunity. The conduct of the child must be the criterion of her +success. If things go wrong, if there is constant crying or +ungovernable temper, if sleep and food are persistently refused, or if +there is undue timidity and tearfulness, there is danger that seeds +may be sown from which nervous disorders will spring in the future.</p> + +<p>There are many women who, without any deep thought on the matter, have +the inborn knack of managing children, who seem to understand them, +and have a feeling for them. With them, we say, the children are +always good, and they are good because the element of nervous +overstrain has not arisen. There are other women, often very fond of +children, who are conspicuously lacking in this power. Contact with +one of these well-meaning persons, even for a few days, will +demoralise a whole nursery. Tempers grow wild and unruly, sleep +disappears, fretfulness and irritability take its place. Yet of most +mothers it is probably true that they are neither strikingly +proficient nor utterly deficient in the power of managing children. If +they lack the gift that comes naturally to some women, they learn from +experience and grow instinctively to feel when they have made a false +step with the +<span class="pagenum">Page 9<a name="Page_9" id="Page_9"></a></span> +child. Although by dearly bought experience they learn +wisdom in the management of their children, they nevertheless may not +study the subject with the same care which they devote to matters of +diet and hygiene. It is the mother whose education and understanding +best fits her for this task. In this country a separate nursery and a +separate nursery life for the children is found in nearly all +households among the well-to-do, and the care for the physical needs +of the children is largely taken off the mothers' shoulders by nurses +and nursemaids. That this arrangement is advantageous on the whole +cannot be doubted. In America and on the Continent, where the children +often mingle all day in the general life of the household, and occupy +the ordinary living rooms, experience shows that nerve strain and its +attendant evils are more common than with us. Nevertheless, the +arrangement of a separate nursery has its disadvantages. Nurses are +sometimes not sufficiently educated to have much appreciation of the +mental processes of the child. If the children are restless and +nervous they are content to attribute this to naughtiness or to +constipation, or to some other physical ailment. Their time is usually +so fully occupied that they cannot be expected to be very zealous in +reading books on the management of children. Nevertheless, in +practical matters of detail a good nurse will learn rapidly from a +mother who has given some attention to the subject, and who is able to +give explicit instructions upon definite points.</p> + +<p><span class="pagenum">Page 10<a name="Page_10" id="Page_10"></a></span> +It is right that mothers should appreciate the important part which +the environment plays in all the mental processes of children, and in +their physical condition as well; that they should understand that +good temper and happiness mean a proper environment, and that constant +crying and fretfulness, broken sleep, refusal of food, vomiting, undue +thinness, and extreme timidity often indicate that something in this +direction is at fault.</p> + +<p>Nevertheless, we must be careful not to overstate our case. We must +remember how great is the diversity of temperament in children—a +diversity which is produced purely by hereditary factors. The task of +all mothers is by no means of equal difficulty. There are children in +whom quite gross faults in training produce but little permanent +damage; there are others of so sensitive a nervous organisation that +their environment requires the most delicate adjustment, and when +matters have gone wrong, it may be very difficult to restore health of +mind and body. When a peculiarly nervous temperament is inherited, +wisdom in the management of the child is essential, and may sometimes +achieve the happiest results. Heredity is so powerful a factor in the +development of the nervous organisation of the child that, realising +its importance, we should be sparing in our criticism of the results +which the mothers who consult us achieve in the training of their +children. A sensitive, nervous organisation is often the mark of +intellectual possibilities above the average, and the children who are +cast outside the ordinary mould, who are +<span class="pagenum">Page 11<a name="Page_11" id="Page_11"></a></span> +the most wayward, the most +intractable, who react to trifling faults of management with the most +striking symptoms of disturbance, are often those with the greatest +potentialities for achievement and for good. It is natural for the +mother of placid, contented, and perhaps rather unenterprising +children, looking on as a detached outsider, seeing nothing of the +teeming activities of the quick, restless little brain, and the +persistent, though faulty reasoning—it is natural for her to blame +another's work, and to flatter herself that her own routine would have +avoided all these troublesome complications. The mother of the nervous +child may often rightly take comfort in the thought that her child is +worth the extra trouble and the extra care which he demands, because +he is sent into the world with mechanism which, just because it is +more powerful than the common run, is more difficult to master and +takes longer to control and to apply for useful ends.</p> + +<p>It is through the mother, and by means of her alone, that the doctor +can influence the conduct of the child. Without her co-operation, or +if she fails to appreciate the whole situation, with the best will in +the world, we are powerless to help. Fortunately with the majority of +educated mothers there is no difficulty. Their powers of observation +in all matters concerning their children are usually very great. It is +their interpretation of what they have observed that is often faulty. +Thus, in the example given above, the mother observes correctly that +defæcation is inhibited, and produces crying +<span class="pagenum">Page 12<a name="Page_12" id="Page_12"></a></span> +and resistance. It is +her interpretation that the cause is to be found in pain that is at +fault. Again, a mother may bring her infant for tongue-tie. She has +observed correctly that the child is unable to sustain the suction +necessary for efficient lactation, and has hit upon this fanciful and +traditional explanation. The doctor, who knows that the tongue takes +no part in the act of sucking, will probably be able to demonstrate +that the failure to suck is due to nasal obstruction, and that the +child is forced to let go the nipple because respiration is impeded. +The opportunities for close observation of the child which mothers +enjoy are so great that we shall not often be justified in +disregarding their statements. But if we are able to give the true +explanation of the symptoms, it will seldom happen that the mother +will fail to be convinced, because the explanation, if true, will fit +accurately with all that has been observed. Thus the mother of the +child in whom defæcation is inhibited by negativism may have made +further observations. For example, she may have noted that the +so-called constipation causes fretfulness, that it is almost always +benefited by a visit to the country or seaside, or that it has become +much worse since a new nurse, who is much distressed by it, has taken +over the management of the child. To this mother the explanation must +be extended to fit these observations, of the accuracy of which there +need be no doubt. Fretfulness and negativism with all children whose +management is at fault come in waves and cycles. The child, naughty +and almost unmanageable one +<span class="pagenum">Page 13<a name="Page_13" id="Page_13"></a></span> +week, may behave as a model of propriety +the next. The negativism and refusal to go to stool are the outcome of +the nervous unrest, not its cause. Again, the nervous child, like the +adult neuropath, very often improves for the time being with every +change of scene and surroundings. It is the <i>ennui</i> and monotony of +daily existence, in contact with the same restricted circle, that +becomes insupportable and brings into prominence the lack of moral +discipline, the fretfulness, and spirit of opposition. Lastly, the +conduct of the nervous child is determined to a great extent by +suggestions derived from the grown-up people around him. Refusal of +food, refusal of sleep, refusal to go to stool, as we shall see later, +only become frequent or habitual when the child's conduct visibly +distresses the nurse or mother, and when the child fully appreciates +the stir which he is creating. The mother will readily understand that +in such a case, where constipation varies in degree according as +different persons take charge of the child, the explanation offered is +that which alone fits with the observed facts. A full and free +discussion between mother and doctor, repeated it may be more than +once, may be necessary before the truth is arrived at, and a line of +action decided upon. Only so can the doctor, remote as he is from the +environment of the child, intervene to mould its nature and shape its +conduct.</p> + +<p>If the doctor is to fit himself to give advice of this sort, he must +be a close observer of little children. He must not consider it +beneath his dignity to study +<span class="pagenum">Page 14<a name="Page_14" id="Page_14"></a></span> +nursery life and nursery ways. There he +will find the very beginnings of things, the growing point, as it +were, of all neuropathy. A man of fifty, who in many other ways showed +evidence of a highly nervous temperament, had especially one +well-marked phobia, the fear of falling downstairs. It had never been +absent all his life, and he had grown used to making the descent of +the stairs clinging firmly to the stair-rail. Family tradition +assigned this infirmity to a fall downstairs in early childhood. But +all children fall downstairs and are none the worse. The persistence +of the fear was due, I make no doubt, to the attitude of the parents +or nurse, who made much of the accident, impressed the occasion +strongly on the child's memory, and surrounded him thereafter with +precautions which sapped his confidence and fanned his fears.</p> + +<p>In what follows we will consider first the subject of nursery +management, searching in it for the origin of the common disorders of +conduct both of childhood and of later life. I have grouped these +nursery observations under the heads of four characteristic features +of the child's psychology—his Imitativeness, his Suggestibility, his +Love of Power, and his acute though limited Reasoning Faculties. I +feel that some such brief examination is necessary if we are to +understand correctly the ætiology of some of the most troublesome +disorders of childhood, such as enuresis, anorexia, dyspepsia, or +constipation, disorders in which the nervous element is perhaps to-day +not sufficiently emphasised. +<span class="pagenum">Page 15<a name="Page_15" id="Page_15"></a></span> +Finally, we can evolve a kind of nursery +psycho-therapeutics—a subject which is not only of fascinating +interest in itself, but which repays consideration by the success +which it brings to our efforts to cure and control.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 16<a name="Page_16" id="Page_16"></a></span></p> +<h3>CHAPTER II</h3> + +<h3>OBSERVATIONS IN THE NURSERY</h3> + +<div class="figcenter"> <br />(<i>a</i>) <span class="subhead">The Imitativeness of the Child</span><br /> </div> + +<p>It is in the second and third years of the child's life that the +rapidity of the development of the mental processes is most apparent, +and it is with that age that we may begin a closer examination. At +first sight it might seem more reasonable to adopt a strictly +chronological order, and to start with the infant from the day of his +birth. Since, however, we can only interpret the mind of the child by +our knowledge of our own mental processes, the study of the older +child and of the later stages is in reality the simpler task. The +younger the infant, the greater the difficulties become, so that our +task is not so much to trace the development of a process from simple +and early forms to those which are later and more complex, as to +follow a track which is comparatively plain in later childhood, but +grows faint as the beginnings of life are approached.</p> + +<p>At the age, then, of two or three the first quality of the child which +may arrest our attention is his extreme imitativeness. Not that the +imitation on his part is in any way conscious; but like a +<span class="pagenum">Page 17<a name="Page_17" id="Page_17"></a></span> +mirror he reflects in every action and in every word all that he sees and hears +going on around him. We must recognise that in these early days his +words and actions are not an independent growth, with roots in his own +consciousness, but are often only the reflection of the words and +actions of others. How completely speech is imitative is shown by the +readiness with which a child contracts the local accent of his +birthplace. The London parents awake with horror to find their baby an +indubitable Cockney; the speech of the child bred beyond the Tweed +proclaims him a veritable Scot. Again, some people are apt to adopt a +somewhat peremptory tone in addressing little children. Often they do +not trouble to give to their voices that polite or deferential +inflection which they habitually use when speaking to older people. +Listen to a party of nurses in the Park addressing their charges. As +if they knew that their commands have small chance of being obeyed, +they shout them with incisive force. "Come along at once when I tell +you," they say. And the child faithfully reflects it all back, and is +heard ordering his little sister about like a drill sergeant, or +curtly bidding his grandmother change her seat to suit his pleasure. +If we are to have pretty phrases and tones of voice, mothers must see +to it that the child habitually hears no other. Again, mothers will +complain that their child is deaf, or, at any rate, that he has the +bad habit of responding to all remarks addressed to him by saying, +"What?" or, worse still, "Eh?" Often +enough the reason that he does so is not +<span class="pagenum">Page 18<a name="Page_18" id="Page_18"></a></span> +that the child is deaf, nor that he is particularly slow to +understand, but simply that he himself speaks so indistinctly that no +matter what he says to the grown-up people around him, they bend over +him and themselves utter the objectionable word.</p> + +<p>We all hate the tell-tale child, and when a boy comes in from his walk +and has much to say of the wicked behaviour of his little sister on +the afternoon's outing, his mother is apt to see in this a most horrid +tendency towards tale-bearing and currying of favour. She does not +realise that day by day, when the children have come in from their +walk, she has asked nurse in their hearing if they have been good +children; and when, as often happens, they have not, the nurse has +duly recounted their shortcomings, with the laudable notion of putting +them to shame, and of emphasising to them the wickedness of their +backsliding—and this son of hers is no hypocrite, but speaks only, as +all children speak, in faithful reproduction of all that he hears. +Those grown-up persons who are in charge of the children must realise +that the child's vocabulary is their vocabulary, not his own. It is +unfortunate, but I think not unavoidable, that so often almost the +earliest words that the infant learns to speak are words of reproof, +or chiding, or repression. The baby scolds himself with gusto, +uttering reproof in the very tone of his elders: "No, no," "Naughty," +or "Dirty," or "Baby shocked."</p> + +<p>Speech, then, is imitative from the first, if we except the early baby +sounds with reduplication +<span class="pagenum">Page 19<a name="Page_19" id="Page_19"></a></span> +of consonants to which in course of time definite meaning becomes +attached, as "Ba-ba," "Ma-ma," "Na-na," +"Ta-ta," and so forth. Action only becomes imitative at a somewhat +later stage. The first purposive movements of the child's limbs are +carried out in order to evoke tactile sensations. He delights to +stimulate and develop the sense of touch. At first he has no knowledge +of distance, and his reach exceeds his grasp. He will strain to touch +and hold distant objects. Gradually he learns the limitations of +space, and will pick up and hold an object in his hand with precision. +Often he conveys everything to his mouth, not because his teeth are +worrying him, or because he is hungry, as we hear sometimes alleged, +but because his mouth, lips, and tongue are more sensitive, because +more plentifully furnished with the nerves of tactile sensation. By +constant practice the sense of touch and the precision of the movement +of his hands are slowly developed, and not these alone, for the child +in acquiring these powers has developed also the centres in the brain +which control the voluntary movements. When the child can walk he +continues these grasping and touching exercises in a wider sphere. As +the child of fifteen or eighteen months moves about the room, no +object within his reach is passed by. He stretches out his hand to +touch and seize upon everything, and to experience the joy of +imparting motion to it. The impulse to develop tactile sensation and +precision in the movements of his hands compels him with irresistible +force. It is foolish to attempt to +<span class="pagenum">Page 20<a name="Page_20" id="Page_20"></a></span> +repress it. It is foolish, because it is a necessary phase in his development, and moreover +a passing phase. No doubt it is annoying to his elders while it lasts, but the +only wise course is to try to thwart as little as we can his +legitimate desire to hold and grasp the objects, and even to assist +him in every way possible. But the mother must assist him only by +allowing free play to his attempts. To hand him the object is to +deprive the exercise of most of its value. Incidentally she may teach +him the virtue of putting things back in their proper places, an +accomplishment in which he will soon grow to take a proper pride. If +she attempts continually to turn him from his purpose, reproving him +and snatching things from him, she prolongs the grasping phase beyond +its usual limits. And she does a worse thing at the same time. Lest +the quicker hands of his nurse should intervene to snatch the prize +away before he has grasped it, he too learns to snatch, with a sudden +clumsy movement that overturns, or breaks, or spills. If left to +himself he will soon acquire the dexterity he desires. He may overturn +objects at first, or let them fall, but this he regards as failure, +which he soon overcomes. A child of twenty months, whose development +in this particular way has not been impeded by unwise repression, will +pick out the object on which he has set his heart, play with it, +finger it, and replace it, and he will do it deliberately and +carefully, with a clear desire to avoid mishap. Dr. Montessori, who +has developed into a system the art of teaching young children to +learn precision +<span class="pagenum">Page 21<a name="Page_21" id="Page_21"></a></span> +of movement and to develop the nerve centres which +control movement, tells in her book a story which well illustrates +this point.<a name="FNanchor_1_1" id="FNanchor_1_1" /><a href="#Footnote_1_1" class="fnanchor">[1]</a></p> + +<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1" /><a href="#FNanchor_1_1"> +<span class="label">[1]</span></a> <i>The Montessori Method</i>, pp. 84, 85.</p></div> + +<p>"The directress of the Casa del Bambini at Milan constructed under one +of the windows a long, narrow shelf, upon which she placed the little +tables containing the metal geometric forms used in the first lesson +in design. But the shelf was too narrow, and it often happened that +the children in selecting the pieces which they wished to use would +allow one of the little tables to fall to the floor, thus upsetting +with great noise all the metal pieces which it held. The directress +intended to have the shelf changed, but the carpenter was slow in +coming, and while waiting for him she discovered that the children had +learned to handle these materials so carefully that in spite of the +narrow and sloping shelf, the little tables no longer fell to the +ground. The children, by carefully directing their movements, had +overcome the defect in this piece of furniture."</p> + +<p>By slow degrees the child learns to command his movements. If his +efforts are aided and not thwarted, before he is two years old he will +have become capable of conducting himself correctly, yet with perfect +freedom. The worst result of the continual repression which may be +constantly practised in the mistaken belief that the grasping phase is +a bad habit which persistent opposition will eradicate, is the nervous +unrest and irritation which it produces in the child. A passionate fit +<span class="pagenum">Page 22<a name="Page_22" id="Page_22"></a></span> +of crying is too often the result of the thwarting of his nature, and +the same process repeated over and over again, day by day, almost hour +by hour, is apt to leave its mark in unsatisfied longing, +irritability, and unrest. Above all, the child requires liberty of +action.</p> + +<p>We have here an admirable example of the effect of environment in +developing the child's powers. A caged animal is a creature deprived +of the stimulus of environment, and bereft therefore to a great extent +of the skill which we call instinct, by which it procures its food, +guarantees its safety from attack, constructs its home, cares for its +young, and procreates its species. If, metaphorically speaking, we +encircle the child with a cage, if we constantly intervene to +interpose something between him and the stimulus of his environment, +his characteristic powers are kept in abeyance or retarded, just as +the marvellous instinct of the wild animals becomes less efficient in +captivity.</p> + +<p>The grasping phase is but a preliminary to more complex activities. +Just as in schooldays we were taught with much labour to make +pot-hooks and hangers efficiently before we were promoted to real +attempts at writing, so before the child can really perform tasks with +a definite meaning and purpose, he must learn to control the finer +movements of his hands. Once the grasping phase, the stage of +pot-hooks, is successfully past—and the end of the second year in a +well-managed child should see its close—the child sets himself with +enthusiasm to wider tasks. To him washing and dressing, fetching +<span class="pagenum">Page 23<a name="Page_23" id="Page_23"></a></span> +his shoes and buttoning his gaiters, all the processes of his simple +little life, should be matters of the most enthralling interest, in +which he is eager to take his part and increasingly capable of doing +so. In the Montessori system there is provided an elaborate apparatus, +the didactic material, designed to cultivate tactile sensation and the +perception of sense stimuli. It will generally suffice to advise the +mother to make use of the ordinary apparatus of the nursery. The +imitativeness of the young child is so great that he will repeat in +almost every detail all the actions of his nurse as she carries out +the daily routine. At eighteen months of age, when the electric light +is turned on in his nursery, the child will at once go to the curtains +and make attempts to draw them. At the same age a little girl will +weigh her doll in her own weighing-machine, will take every precaution +that the nurse takes in her own case, and will even stoop down +anxiously to peer at the dial, just as she has seen her mother and +nurse do on the weekly weighing night. But at a very early age +children appreciate the difference between the real and the +make-believe. They desire above all things to do acts of real service. +At the age of two a child should know where every article for the +nursery table is kept. He will fetch the tablecloth and help to put it +in place, spoons and cups and saucers will be carried carefully to the +table, and when the meal is over he will want to help to clear it all +away. All this is to him a great delight, and the good nurse will +encourage it in the children, because she sees that in doing so they +gain quickness and dexterity and +<span class="pagenum">Page 24<a name="Page_24" id="Page_24"></a></span> +poise of body. The first purposive +movements of the child should be welcomed and encouraged. It is +foolish and wrong to repress them, as many nurses do, because the +child in his attempts gets in the way, and no doubt for a time delays +rather than expedites preparations. The child who is made to sit +immobile in his chair while everything is done for him is losing +precious hours of learning and of practice. It is useless, and to my +mind a little distasteful, to substitute for all this wonderful child +activity the artificial symbolism of the kindergarten school in which +children are taught to sing songs or go through certain semi-dramatic +activities which savour too much of a performance acquired by precise +instruction. If such accomplishments are desired, they may be added +to, but they must not replace, the more workaday activities of the +little child. The child whose impulses towards purposive action are +encouraged is generally a happy child, with a mind at rest. When those +impulses are restrained, mental unrest and irritability are apt to +appear, and toys and picture books and kindergarten games will not be +sufficient to restore his natural peace of mind.</p> + + +<div class="figcenter"> <br />(<i>b</i>) <span class="subhead">The Suggestibility of the Child</span><br /> </div> + +<p>We may pass from considering the imitativeness of the child to study a +second and closely related quality, his suggestibility. His conception +of himself as a separate individual, of his ego, only gradually +emerges. It is profoundly modified by ideas +<span class="pagenum">Page 25<a name="Page_25" id="Page_25"></a></span> +derived from those around +him. Because of his lack of acquired experience, there is in the child +an extreme sensitiveness to impressions from outside. Take, for +example, a matter that is sometimes one of great difficulty, the +child's likes and dislikes for food. Many mothers make complaint that +there are innumerable articles of diet which the child will not take: +that he will not drink milk, or that he will not eat fat, or meat, or +vegetables, or milk puddings. There are people who believe that these +peculiarities of taste correspond with idiosyncrasies of digestion, +and that children instinctively turn from what would do them harm. I +do not believe that there is much truth in this contention. If we +watch an infant after weaning, at the time when his diet is gradually +being enlarged to include more solid food, with new and varied +flavours, we may see his attention arrested by the strange sensations. +With solid or crisp food there may be a good deal of hesitation and +fumbling before he sets himself to masticate and swallow. With the +unaccustomed flavour of gravy or fruit juice there may be seen on his +face a look of hesitation or surprise. In the stolid and placid child +these manifestations are as a rule but little marked, and pleasurable +sensations clearly predominate. With children of more nervous +temperament it is clear that sensations of taste are much more acute. +Even in earliest infancy, children have a way of proclaiming their +nervous inheritance by the repugnance which they show to even trifling +changes in the taste or composition of their food. We see +<span class="pagenum">Page 26<a name="Page_26" id="Page_26"></a></span> +the same sensitiveness in their behaviour to medicines. The mixture which one +child will swallow without resentment, and almost eagerly, provokes +every expression of disgust from another, or is even vomited at once. +In piloting the child through this phase, during which he starts +nervously at all unaccustomed sensations and flavours, the attitude of +mother and nurse is of supreme importance. It is unwise to attempt +force; it is equally unwise, by excessive coaxing, cajoling, and +entreaty, to concentrate the child's attention on the matter. If +either is tried every meal is apt to become a signal for struggling +and tears. The phase, whether it is short or long continued, must be +accepted as in the natural order of things, and patience will see its +end. The management of this symptom,—refusal of food and an +apparently complete absence of desire for food,—which is almost the +commonest neurosis of childhood, will be dealt with later. Here it is +mentioned because I wish to emphasise that if too much is made of a +passing hesitation over any one article of food, if it becomes the +belief of the mother or nurse that a strong distaste is present, then +if she is not careful her attitude in offering it, because she is +apprehensive of refusal, will exert a powerful suggestion on the +child's mind. Still worse, it may cause words to be used in the +child's hearing referring to this peculiarity of his. By frequent +repetition it becomes fixed in his mind that this is part of his own +individuality. He sees himself—and takes great pleasure in the +thought—as a strange child, who by these peculiarities creates +<span class="pagenum">Page 27<a name="Page_27" id="Page_27"></a></span> +considerable interest in the minds of the grown-up people around him. +When the suggestion takes root it becomes fixed, and as likely as not +it will persist for his lifetime. It may be habitually said of a child +that, unlike his brothers and sisters, he will never eat bananas, and +thereafter till the day of his death he may feel it almost a physical +impossibility to gulp down a morsel of the offending fruit. So, too, +there are people who can bolt their food with the best of us, who yet +declare themselves incapable of swallowing a pill.</p> + +<p>Another example of the force of suggestion, whether unconscious or +openly exercised by speech, is given us in the matter of sleep. Among +adults the act of going to bed serves as a powerful suggestion to +induce sleep. Seldom do we seek rest so tired physically that we drop +off to sleep from the irresistible force of sheer exhaustion. Yet as +soon as the healthy man whose mind is at peace, whose nerves are not +on edge, finds himself in bed, his eyes close almost with the force of +a hypnotic suggestion, and he drops off to sleep. With some of us the +suggestion is only powerful in our own bed, that on which it has acted +on unnumbered nights. We cannot, as we say, sleep in a strange bed. It +is suggestion, not direct will power, that acts. No one can absolutely +will himself to sleep. In insomnia it is the attempt to replace the +unconscious auto-suggestion by a conscious voluntary effort of will +that causes the difficulty. A thousand times in the night we resolve +that now we <i>will</i> sleep. If we could but cease to make these fruitless efforts, +<span class="pagenum">Page 28<a name="Page_28" id="Page_28"></a></span> +sleep might come of itself and the suggestion or habit be re-established.</p> + +<p>In little children the suggestion of sleep, provoked by being placed +in bed, sometimes acts very irregularly. Often it may succeed for a +week or two, and then some untoward happening breaks the habit, and +night after night, for a long time, sleep is refused. The wakeful +child put to bed, resents the process, and cries and sobs miserably, +to the infinite distress of his mother. It then becomes just as likely +that the child will connect his bed in his mind, not with rest and +sleep, but with sobbing and crying on his part, and mingled entreaties +and scoldings from his nurse or mother. An important part in this +perversion of the suggestion is played by the attitude of the person +who puts the child to bed. Often the nurse is uniformly successful, +while the mother, who is perhaps more distressed by the sobbing of the +child, as consistently fails, because she has been unable to hide her +apprehension from him, and has conveyed to his mind a sense of his own +power.</p> + +<p>Just in the same way, grown-up people, filled with anxiety because of +the helplessness of the young child, unable to divest their minds of +the fears of the hundred and one accidents that may befall, or that +within their own experience have befallen, a little child at one time +or another, unconsciously make unwise suggestions which fill his mind +with apprehension and terror. They do not like their children to show +fear of animals. Nor would they if it were not that their own +apprehension that the child may be hurt communicates +<span class="pagenum">Page 29<a name="Page_29" id="Page_29"></a></span> +itself to him. The child is not of himself afraid to fall, it is they who suffer the +anxiety and show it by treating the fall as a disaster. The child is +not of himself afraid to be left alone in a room. It is they who sap +his confidence in himself, because they do not venture to leave him +out of their sight, from a nameless dread of what may happen. A little +girl cut her finger and ran to her nurse, pleased and interested: +"See," she said, seeing it bleed, "fingers all jammy." Only when the +nurse grasped her with unwise expressions of horror did she break into +cries of fear. A town-bred nurse, who is afraid of cows, will make +every country walk an ordeal of fear for the children.</p> + +<p>Every mother must be made to realise the ease with which these +unconscious suggestions act upon the mind of the little child, and +should school herself to be strong to make her child strong, and to +see to it that all this suggestive force is utilised for good and not +for evil.</p> + +<p>It is upon this susceptibility to suggestion that a great part of his +early education reposes. No one who is incapable of profiting by this +natural disposition of the child can be successful in her management +of him. Turn where you will in his daily life the influence of this +force of suggestion is clearly apparent. The child does without +questioning that which he is confidently expected to do. Thus he will +eat what is given him, and sleep soundly when he is put to bed if only +the appropriate suggestion and not the contrary is made to him. Again +we have seen that a perversion of suggestion of this +<span class="pagenum">Page 30<a name="Page_30" id="Page_30"></a></span> +sort is a common source of constipation in early childhood. If the child's +attention is directed towards the difficulty, if he is urged or ordered or +appealed to to perform his part, if failure is looked upon as a serious +misfortune, the bowels may remain obstinately unmoved. In children as +in adults a too great concentration of attention inhibits the action +of the bowels, and constipation, in many persons, is due to the +attempt to substitute will power for the force of habitual suggestion. +No matter what other treatment we adopt, the mother must be careful to +hide from the child that his failure is distressing to her. A cheerful +optimism which teaches him to regard himself as one who is +conspicuously regular in his habits, and who has a reputation in this +respect to live up to is sure to succeed. To talk before him of his +habitual constipation, and to worry over the difficulty, is as surely +to fail. In the same way unwise suggestion can interfere with the +passing of water at regular and suitable intervals. There are children +who constantly desire to pass water on any occasion, which is +conspicuously inappropriate, because their attention has been +concentrated on the sensations in the bladder. Often enough when at +great inconvenience opportunity has been found, the desire has passed +away, and all the trouble has proved needless. It is not too much to +say that every occupation and every action of the day can be made +delightful or hateful to the child, according to the suggestion with +which it is presented and introduced. Dressing and undressing, eating +and drinking, +<span class="pagenum">Page 31<a name="Page_31" id="Page_31"></a></span> +bathing, washing, the putting away of toys, even going +to bed, can be made matters of enthralling interest or delight, or a +subject for tears and opposition, according to the bias which is given +to the child's mind by the words, attitude, and actions of nurses and +mothers.</p> + +<p>Here we approach very near to the heart of the subject. Stripped of +all that is not essential we see the problem of the management of +children reduced to the interplay between the adult mind and the mind +of the receptive suggestible child. That which is thought of and +feared for the child, that he rapidly becomes. Placid, comfortable +people who do not worry about their children find their children +sensible and easy to manage. Parents who take a pride in the daring +and naughty pranks of their children unconsciously convey the +suggestion to their minds that such conduct is characteristic of them. +Nervous and apprehensive parents who are distressed when the child +refuses to eat or to sleep, and who worry all day long over possible +sources of danger to him, are forced to watch their child acquire a +reputation for nervousness, which, as always, is passively accepted +and consistently acted up to. Differences in type, determined by +hereditary factors, no doubt, exist and are often strongly marked. Yet +it is not untrue to say that variations in children, dependent upon +heredity, show chiefly in the relative susceptibility or +insusceptibility of the child to the influences of environment and +management. It is no easy task to distinguish between the nervous +child and the child of the +<span class="pagenum">Page 32<a name="Page_32" id="Page_32"></a></span> +nervous mother, between the child who +inherits an unusually sensitive nervous system and the child who is +nervous only because he breathes constantly an atmosphere charged with +doubt and anxiety.</p> + + +<div class="figcenter"> <br />(<i>c</i>) <span class="subhead">The Child's Love of Power</span><br /> </div> + +<p>Let us study briefly a third quality of the child which, for want of a +better name, I have called after the ruling passion of mankind, his +love of power. Perhaps it would be better to call it his love of being +in the centre of the picture. It is his constant desire to make his +environment revolve around him and to attract all attention to +himself. Somewhat later in life this desire to attract attention, at +all costs, is well seen in the type of girl popularly regarded as +hysterical. The impulse is then a morbid and debased impulse; in the +child it is natural and, within limits, praiseworthy. A girl of this +sort, who feels that she is not likely to attract attention because of +any special gifts of beauty or intellect which she may possess, +becomes conscious that she can always arouse interest by the severity +of her bodily sufferings. The suggestion acts upon her unstable mind, +and forthwith she becomes paralysed, or a cripple, or dumb, presenting +a mimicry or travesty of some bodily ailment with which she is more or +less familiar. "Hysterical" girls will even apply caustic to the skin +in order to produce some strange eruption which, while it sorely +puzzles us doctors, will excite widespread interest and commiseration. +Now little +<span class="pagenum">Page 33<a name="Page_33" id="Page_33"></a></span> +children will seldom carry their desire to attract +attention so far as to work upon the feelings of their parents by +simulating disease. They have not the necessary knowledge to play the +part, and even if they make the attempt, complaining of this or that +symptom which they notice has aroused the interest of their elders, +the simulation is not likely to be so successful as to deceive even a +superficial observer. But within the limits of their own powers, +children are past masters in attracting attention. The little child is +unable to take part in any sustained conversation; most of his +talking, indeed, is done when he is alone, and is addressed to no one +in particular. But he knows well that by a given action he can produce +a given reaction in his mother and nurse. A great part of what is said +to him—too great a part by far—comes under the category of reproof +or repression. He is forbidden to do this or that, coaxed, cajoled, +threatened long before he is old enough to understand the meaning of +the words spoken, although he knows the tone in which they are uttered +and loves to produce it at will. How he enjoys it all! Watch him draw +near the fire, the one place that is forbidden him. He does not mean +to do himself harm. He knows that it is hot and would hurt him, but +for the time being he is out of the picture and he is intent on +producing the expected response, the reproof tone from his mother +which he knows so well. He approaches it warily, often anticipating +his mother's part and vigorously scolding himself. He desires nothing +more than that his mother should repeat the reproof, forbidding +<span class="pagenum">Page 34<a name="Page_34" id="Page_34"></a></span> +him a dozen times. The mind of all little children tends easily to work in a +groove. It delights in repetition and it evoking not the unexpected +but the expected. If his sport is stopped by his mother losing +patience and removing him bodily from the danger zone, his sense of +impotence finds vent in passionate crying. But if his mother takes no +notice, the sport soon loses its savour. He is conscious that somehow +or other it has fallen flat, and he flits off to other employment.</p> + +<p>Mothers will complain that children seem to take a perverse pleasure +in evoking reproof, appeals, entreaties, and exhortations. A small boy +of four who had several times repeated the particular sin to which his +attention had been directed by the frequency of his mother's warnings +and entreaties, finding that on this occasion she had decided to take +no notice, approached her with a troubled face: "Are you not angry?" +he said; "are you not disappointed?" In reality the naughty child is +often only the child who has become master of his mother's or his +nurse's responses, and can produce at will the effect he desires. The +idea that the child possesses a strong will, which can and must be +broken by persistent opposition, is based upon this tendency of the +child. It is an entire misconception of the situation: Strength of +will and fixity of purpose are among the last powers which the human +mind develops. In little children they are conspicuously absent. What +appears to us as a fixed and persistent desire to perform a definite +action in spite of all we can say or do, is often no more than +<span class="pagenum">Page 35<a name="Page_35" id="Page_35"></a></span> +the desire to produce the familiar tones of reproof, to traverse again the +familiar ground, to attract attention and to find himself again the +centre of the picture. If no one pays any attention and no one +reproves, he soon gives up the attempt. If too much is made of any one +action of the child, a strong impression is made on his mind and he +cannot choose but return to it again and again.</p> + +<p>This little drama of the fireplace may teach us a great deal in the +management of children. The wise mother and nurse will find a hundred +devices to catch the child's attention and lure him away from the +danger zone without the incident making any impression on his mind at +all, and will not call attention to it by repeated reproofs or +warnings which will certainly lead him straight back to the spot.</p> + +<p>In matters of greater moment the same impulse to oppose the will of +those around him is seen. In considering the point of the child's +susceptibility to suggestion, we have mentioned the refusal of sleep +and the refusal of food. In both it is possible to detect the +influence of this pronounced force of opposition. As the child lies +sobbing or screaming in bed, every new approach to him, every fresh +attempt at pacification, renews the force of his opposition in a +crescendo of sound. But it is in his refusal of food that the child is +apt to find his chief opportunity. Meal-times degenerate into a +struggle. There at least he can show his complete mastery of the +situation. No one can swallow his food for him, and he knows it. He +can clench his teeth and shake his head and obstinately refuse every +morsel offered. +<span class="pagenum">Page 36<a name="Page_36" id="Page_36"></a></span> +He can hold food in his mouth for half an hour at a +time and remain deaf to all the appeals of his helpless nurse. If she +tries force, he quells the attempt by a storm of crying. If she +declines upon entreaty and coaxing, he will not be persuaded. It is +the little scene of the fireplace over again. The attempts at force or +the attempts at persuasion, by making much of it, have concentrated +the attention of the child upon the difficulty, and have taught him +his own power to dominate the situation.</p> + +<p>It is right that parents should realise that the disturbing and +irritating element in the child's environment is nearly always +provided by the intrusion of the adult mind and its contact with the +child's. Some supervision and some intrusion, therefore, is of course +absolutely necessary, but the best-regulated nursery is that in which +it is least evident. Something is definitely wrong if a child of two +years will not play for half an hour at a time happily and busily in a +room by himself. It is an even better test if the child will play +amicably by himself with nurse or mother in the room, without the two +parties crossing swords on a single occasion, without reproof or +repression on the one side or undue attempts to attract attention on +the other. If the child is entirely dependent upon the participation +of grown-up persons in his pursuits, then not only do those pursuits +lose much of their educative force, but they become a positive source +of danger because of the constant interplay of personality with +personality. The child who, seated on the ground, will play with his +toys by himself, rises +<span class="pagenum">Page 37<a name="Page_37" id="Page_37"></a></span> +with a brain that is stimulated but not +exhausted. Only very rarely do we find that solitary play, or play +between children, is too exciting. In older children of very quick +intelligence and nervous temperament we occasionally find that the +pace which they themselves set is too exciting or exhausting. I recall +a little boy of seven, an only child of particularly wise and +thoughtful parents, who was brought to me with the complaint that he +exhausted himself utterly both in body and mind by the intense nervous +energy which he threw into his pursuits. For instance, he had been +interested in the maps illustrating the various fronts in the European +War, with which the walls of his father's study were hung, and +although left entirely by himself he had become intensely excited and +exhausted by the eagerness with which he had spent a whole morning, +with a wealth of imaginative force, in drawing a map of the garden of +his house and converting it into the likeness of a war map, filled +with imaginary Army Corps. Such excessive expenditure of nervous force +is unusual even in older children, and as in this case is found +usually only when there is a pronounced nervous inheritance. In little +children in the nursery, solitary play or play between themselves +seldom produces nervous exhaustion. It is quite otherwise when the +child is dependent to a too great extent upon the participation of +adults. It is almost impossible for the mother and nurse not to take +the leading part in the exchange of ideas, and no matter what may be +their good intentions, the pace set is apt to +<span class="pagenum">Page 38<a name="Page_38" id="Page_38"></a></span> +be too great. Environment, without the intrusion of the adult mind, is best able to +adjust the necessary stimulus and produce development without +exhaustion. Play with grown-up persons, the reading aloud of story +books, the showing of pictures, and so forth, undoubtedly have their +own importance, but they should be confined within strict limits and +to a definite hour in the daily routine. There is sometimes too great +a tendency for parents to make playthings of their little children. +Save at stated times, they must curb their desire to join in their +games, to gather them in their arms, to hold them on their knee, while +they stimulate their minds by a constant succession of new +impressions. With an only child, whose existence is the single +preoccupation of the nurse and mother, and, often enough, of the +father as well, it is difficult to avoid this fault. Yet, if wisdom is +not learnt, the damage to the child may be distressingly serious. He +rapidly grows incapable of supporting life without this excessive +stimulation. Without the constant society and attention of a grown +person, he feels himself lost. He cannot be left alone, and yet cannot +enjoy the society he craves. He grows more and more restless, +dominating the whole situation more and more, constantly plucking at +his nurse's skirts, perversely refusing every new sensation that is +offered him to still his restlessness for a moment. The result of all +this stimulation is mental irritability and exhaustion, which in turn +is often the direct cause of refusal of food, dyspepsia, wakefulness, +and excessive crying.</p> + +<p><span class="pagenum">Page 39<a name="Page_39" id="Page_39"></a></span> +The devices by which children will attract to themselves the +attention of their elders, and which, if successful, are repeated with +an almost insane persistence, take on the most varied forms. Sometimes +the child persistently makes use of an expression, or asks questions, +which produce a pleasant stir of shocked surprise and renewed reproofs +and expostulations. One little boy shouted the word "stomachs" with +unwearied persistence for many weeks together. A little girl dismayed +her parents and continued in spite of all they could do to prevent her +to ask every one if they were about to pass water.</p> + +<p>Disorders of conduct of this sort are not really difficult to control. +Suitable punishment will succeed, provided also that the child is +deprived of the sense of satisfaction which he has in the interest +which his conduct excites. His behaviour is only of importance because +it indicates certain faults in his environment and a certain element +of nervous unrest and overstrain.</p> + +<p>The young child demands from his environment that it should give him +two things—security and liberty. He must have security from shocks to +his nervous system. It is true that from the greater shocks the +children of the well-to-do are as a rule carefully guarded. No one +threatens or ill-uses them. They are not terrified by drunken brawls +or scenes of passion. They are not made fearful by the superstitions +of ignorant people. Nevertheless, by the summation of stimuli little +emotions constantly repeated can have effects no less grave +<span class="pagenum">Page 40<a name="Page_40" id="Page_40"></a></span> +upon their nervous system. From this constantly acting irritation the child +needs security. In the second place, he requires liberty to develop +his own initiative, which should be stimulated and sustained and +directed. Without liberty and without security conduct cannot fail to +become abnormal.</p> + + +<div class="figcenter"> <br />(<i>d</i>) <span class="smcap">The Reasoning Power of the Child</span><br /> </div> + +<p>Before we proceed to a closer examination of the various symptoms of +nervous unrest in detail, we may very briefly consider the scope and +power of the child's understanding. As a rule I am sure that it is +grossly underestimated. The mental processes of the child are far +ahead of his power of speech. The capacity for understanding speech is +well advanced, and an appeal to reason is often successful while the +child is still powerless to express his own thoughts in words. Because +he cannot so express himself there is a tendency to underestimate the +acuteness of his reasoning, to talk down to him, and to imagine that +he can be imposed upon by any fiction which seems likely to suit the +purpose of the moment. A child of eighteen months is not too young to +be talked to in a quiet, straightforward, sensible way. Only if he is +treated as a reasonable being can we expect his reasoning faculties to +develop. Children dislike intensely the unexplained intervention of +force. If a pair of scissors, left by an oversight lying about, has +been grasped, the first impulse of the mother is to snatch the danger +hurriedly from the child's hands, and +<span class="pagenum">Page 41<a name="Page_41" id="Page_41"></a></span> +her action will generally be +followed by resistance and a storm of weeping. She will do better to +approach him quietly, telling him that scissors hurt babies, and show +him where to place them out of harm's way. Watch a child at play after +his midday meal. He has been out in his perambulator half the morning, +and for the other half has been deep in his midday sleep. Now that +dinner is over he is for a moment master of his time and busily +engaged in some pursuit dear to his heart. At two o'clock inexorable +routine ordains that he must again be placed in the perambulator and +wheeled forth on a fresh expedition. If the nurse does not know her +business she will swoop down upon him, place him on her knee, and +begin to envelop his struggling little body in his outdoor clothes, +scolding his naughtiness as he kicks and screams. If she has a way +with children she will open the cupboard door and call on him to help +find his gaiters and his shoes because it is time for his walk. In a +moment he will leave his toys, forgetting all about them in the joy of +this new activity.</p> + +<p>If the reason for things is explained to children they grow quick to +understand quite complicated explanations. A little girl, not yet two, +was playing with her Noah's Ark on the dining-room table with its +polished surface. The mother interposed a cloth, explaining that the +animals would scratch the table if the cloth were not there. Within a +few minutes the child twice lifted the cloth, peering under it and +saying, "Not scratch table." Yet +<span class="pagenum">Page 42<a name="Page_42" id="Page_42"></a></span> +how often do we find +facetiously-minded persons confound their reasoning and confuse their +judgment by foolish speeches and cock-and-bull tales, which, just +because of their foolishness, seem to them well adapted to the infant +intelligence.</p> + +<p>An attempt to deceive the child is almost always wrong, and because of +our tendency to underestimate the child's intelligence it generally +fails. If a little girl has a sore throat, and the doctor comes to see +her, she knows quite well that she is the prospective patient. It is +useless for the mother to begin proceedings by trying to convince her +that this is not so—that mother has a sore throat too. Such a plan +only arouses apprehension, because the child scents danger in the +artifice.</p> + +<p>Closely connected with the reasoning powers of the child is the +difficult question of the growth of his appreciation of right and +wrong, or, to put it in another way, the growth of obedience or +disobedience. Sooner or later the child must learn to obey; on that +there can be no two opinions. Nevertheless, I think there can be no +doubt that far more harm is done by an over-emphasis of authority than +by its neglect. If the nurse or mother is of strong character, and the +authority is exercised persistently and remorselessly, so that the +whole life of the child is dominated, much as the recruit's existence +in the barrack yard is dominated by the drill sergeant, his +independence of nature is crushed. He is certain to become a +colourless and uninteresting child; he runs a grave risk of growing +sly, broken-spirited, and a currier of favour. If a child is ruthlessly +<span class="pagenum">Page 43<a name="Page_43" id="Page_43"></a></span> +punished for disobedience from his earliest years, there +is, it need hardly be said, a grave risk that he will learn to lie to +save his skin. I have seen a few such cases of what I may call the +remorseless exercise of authority, and the result has not been +pleasing. Fortunately, perhaps, not many women have the heart to adopt +this attitude to the waywardness of little children—a waywardness to +which their whole nature compels them by their pressing need to +cultivate tactile sensations, to experiment, and to explore. +Therefore, much more commonly, the authority is exercised +intermittently and capriciously, with the result that the child's +judgment is clouded and confused. Conduct which is received +indulgently or even encouraged at one moment is sternly reprimanded at +another. Every one who has the management of little children must +above all see to it, whatever the degree of stringency in discipline +which they decide to adopt, that their attitude is always consistent. +The less that is forbidden the better, but when the line is drawn it +must be adhered to. If once the child learns that the force which +restrains him can be made to yield to his own efforts, the future is +black indeed. From that day he sets himself to strike down authority +with a success which encourages him to further efforts. I have known a +child of five years terrorise his mother and get his own way by the +threat, "I will go into one of my furies."</p> + +<p>The difficulty of successfully enforcing authority, and of carrying +off the victory if that authority is disputed, should make mothers +wary of drawing +<span class="pagenum">Page 44<a name="Page_44" id="Page_44"></a></span> +too tight a rein. The conflict between parent and +child must always be distressing and must always be prejudicial to the +child, whatever its outcome, whether it brings to him victory or +defeat. He learns from it either an undue sense of power or an undue +sense of helplessness, and the knowledge of neither is to his benefit. +Although frequently worsted in the conflict, nurses will often return +to the attack again and again and hour after hour, restraining, +reproving, forbidding, and even threatening. Nor do they see that they +are really goading the children into disobedience by their misdirected +efforts at enforcing discipline. Reproof, like punishment, loses all +its effect when it is too often repeated, and the child soon takes it +for granted that all he does is wrong, and that grown-up people exist +only to thwart his will, to misunderstand, to reprove, or even to +punish.</p> + +<p>In the nursery the word "naughty" is far too frequently heard. It is +naughty to do this, it is naughty to do that. There is no gradation in +the condemnation, and the child loses all sense of the meaning of the +word. He himself proclaims himself naughty almost with satisfaction: +his doll is naughty, the dog is naughty, his nurse and mother are +naughty, and so forth. In reality the little child is peculiarly +sensitive to blame, if he is not reproof-hardened. It is hardly +necessary to use words of blame at all. If he is asked kindly and +quietly to desist, much as we would address a grown-up person, and +does not, he can be made to feel that his conduct is unpopular by +keeping aloof from him a +<span class="pagenum">Page 45<a name="Page_45" id="Page_45"></a></span> +little, by disregarding him for the time +being, and by indicating to him that he is a troublesome little person +with whom we cannot be bothered.</p> + +<p>Any one who has had much to do with children will realise that, if +wrongly handled, they are apt to take a positive delight in doing what +they conceive to be wrong. There is clearly a delightful element of +excitement in the process of being naughty, of daring and of braving +the wrath to come, with which they are so familiar and for which they +care nothing at all. But the perverseness of which we are now speaking +has a different origin. It arises only when children are reproved, +appealed to, and expostulated with too often and too constantly. +Negativism is a symptom which is common enough in certain mental +disorders. The unhappy patient always does the opposite of what is +desired or expected of him. If he be asked to stand up he will +endeavour to remain seated, or if asked to sit he will attempt to rise +to his feet. Like many other symptoms of nervous disturbance which we +shall study later, this negativistic spirit is often displayed to +perfection by little children when the environment is at fault and +when grown-up people have too freely exercised authority. A mother, +anxious to induce her little son to come to the doctor, and knowing +well that her call to him to enter the room, as he stands hesitating +at the door, will at once determine his retreat to the nursery, has +been heard to say, "Run away, darling, we don't want <i>you</i> here," with +the expected result that the docile child immediately comes +<span class="pagenum">Page 46<a name="Page_46" id="Page_46"></a></span> +forward. To the doctor, that such a device should be practised almost as a +matter of course and that its success should be so confidently +anticipated, should give food for thought. It may shed light on much +that is to follow later in the interview.</p> + +<p>The question of punishment, like that of reproof, is beset with +difficulty. There are fortunately nowadays few educated mothers who +are so foolish as to threaten punishment which they obviously do not +intend to administer and which the child knows they will not +administer. It is clear that punishment must be rare or else the child +will grow habituated to it, and with little children we cannot be +brutal or push punishment to the point of extreme physical pain. It is +more difficult to say, as one is tempted to say, that all punishment +is futile and should be discarded. Probably mothers are like +schoolmasters in that no two schoolmasters and no two mothers obtain +their effects in exactly the same way or by precisely the same means. +Nor do all children accept reproof or submit to punishment in the same +way. Some make light of it and take a pleasure in defying authority. +Others are unduly cast down by the slightest adverse criticism. It is +generally true that extreme sensitiveness to reproof is a sign of a +certain elevation of character. Always we must remember that for a +mother to inflict punishment, whether by causing physical pain or +mental suffering, is to take on her shoulders a certain +responsibility. It is a serious matter if she has misapprehended the +child's act—if the sin was not really a sin, but only some perverted +action, the intention +<span class="pagenum">Page 47<a name="Page_47" id="Page_47"></a></span> +of which was not sinful, but designed for good +in the faulty reasoning of the child. A little girl, in bed with a +feverish cold, was found shivering, with her night-dress wet and +muddy. It was an understanding mother who found that her little +brother, having heard somehow that ice was good for fevered heads, had +brought in several handfuls of snow from the garden, not of the +cleanest, and had offered them to aid his sister's recovery. It need +hardly be said that punishment should always be deliberate. The hasty +slap is nothing else than the motor discharge provoked by the +irritability of the educator, and the child, who is a good observer on +such points, discerns the truth and measures the frailty of his judge.</p> + +<p>The frequent repetition of words of reproof and acts of punishment has +a further disadvantage that the older children are quick to practise +both upon their younger brothers and sisters. There is something wrong +in the nursery where the lives of the little ones are made a burden to +them by the constant repression of the older children. But although +set and artificial punishments are as a general rule to be used but +sparingly, the mother can see to it that the child learns by +experience that a foolish or careless act brings its own punishment. +If, for example, a child breaks his toy, or destroys its mechanism, +she need not be so quick in mending it that he does not learn the +obvious lesson. If the baby throws his doll from the perambulator, in +sheer joy at the experience of imparting motion to it, she need not +prevent him from learning the +<span class="pagenum">Page 48<a name="Page_48" id="Page_48"></a></span> +lesson that this involves also some +temporary separation from it. Throughout all his life he is to learn +that he cannot eat his cake and have it too. The use of rewards is +also beset with difficulties. Their coming must be unexpected and +occasional. They must never degenerate into bribes, to be bargained +for upon condition of good behaviour. Rewards which take the form of +special privileges are best.</p> + +<p>The æsthetic sense of children develops very early. From the very +beginning of the second year they take delight in new clothes, and in +personal adornment of all sorts. They show evident pleasure if the +nursery acquires a new picture or a new wall-paper. They have +pronounced favourites in colours. Even tiny children show dislike of +dirt and all unpleasant things. Personal cleanliness should be clearly +desired by all children. A sense of what is pleasant and what is +unpleasant should be encouraged. Any delay in its appearance is apt to +imply a backwardness in development of mind or of body. Only children +who are tired out by physical illness or by nervous exhaustion will +lie without protest in a dirty condition.</p> + +<p>Affection and the attempt to express affection appear clearly marked +even in the first year. Too much kissing and too much being kissed is +apt to spoil the spontaneity of the child's caresses. We must not, +however, expect to find any trace in the young child of such a complex +quality as unselfishness or self-abnegation. The child's conception of +his own self has but just emerged. It is his single impulse to develop +his own experience and his own +<span class="pagenum">Page 49<a name="Page_49" id="Page_49"></a></span> +powers, and his attitude for many years is summed up in the phrase: +"Me do it." We must not expect him +to resign his toys to the little visitor, or the little visitor to +cease from his efforts to obtain them. In all our dealings with +children we must know what we may legitimately expect from them, and +judge them by their own standards, not by those of adult life. We +cannot expect self-sacrifice in a child, and, after all, when we come +to think of it, obedience is but another name for self-sacrifice. If +the tiny child could possibly obey all the behests that are heaped +upon him in the course of a day by many a nurse and mother, he would +truly be living a life of complete self-abnegation. Surely it is +because the virtue of obedience, the virtue that is proclaimed +proverbially the child's own, is so impossible of attainment that it +is become the subject of so much emphasis. As Madame Montessori has +put it: "We ask for obedience and the child in turn asks for the +moon." Only when we have developed the child's reasoning powers, by +treating him as a rational being, can we expect him deliberately to +defer his wishes to ours, because he has learned that our requests are +generally reasonable.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 50<a name="Page_50" id="Page_50"></a></span></p> +<h3>CHAPTER III</h3> + +<h3>WANT OF APPETITE AND INDIGESTION</h3> + + +<p>The mind of the child is so unstable and yet so highly developed, that +symptoms of nervous disturbance are more frequent and of greater +intensity than in later life. Only rarely and in exceptional cases do +certain symptoms, common in childhood, persist into adult life or +appear there for the first time, and then usually in persons who, if +they are not actually insane, are at least suffering from intense +nervous strain. We have already mentioned the symptom of negativism +and noted its occasional occurrence as an accompaniment of mental +disorder in adult life, and its frequency among children who are +irritable or irritated. Similarly, we may cite the digestive neuroses +of adult life to explain the common refusal of food and the common +nervous vomiting of the second year of life. Thus, for example, there +exists in adult life a disturbance of the nervous system which is +called "anorexia nervosa." A boy of nineteen was brought to the +Out-patient Department of Guy's Hospital suffering from this +complaint. He was little more than a skeleton, unable to stand, hardly +able to sit, and weighing +<span class="pagenum">Page 51<a name="Page_51" id="Page_51"></a></span> +only four and a half stones. His mother, +who came with him, stated that he had always been nervous, and that +lately, after receiving a call to join the army as a recruit, his +appetite, which had for some time been capricious, had completely +disappeared. In spite of coaxing he resolutely refused all food, or +took it only in the tiniest morsels, although at the same time it was +thought that he sometimes took food "on the sly." A careful +examination showed absolutely no sign of bodily disease. He was +admitted to a ward for treatment by hypnotic suggestion, but before +this could be begun he endeavoured to commit suicide by setting fire +to his bed.</p> + +<p>A girl of twenty-four years of age had become almost equally +emaciated. Constant vomiting had persisted for many years and had +defied many attempts at cure. It had even been proposed to perform the +operation of gastro-enterostomy in the belief that some organic +disease existed. In suitable surroundings and with the energetic +support of a good nurse, who spent much time and care in restoring her +balance of mind, the vomiting ceased, and she gained over two stones +in weight. Work was found for her in some occupation connected with +the War, and she left the Nursing Home to undertake this, bearing with +her four pounds which she had abstracted from the purse of another +patient.</p> + +<p>Those who have not opportunities of observing how all-powerful is the +effect of the mind upon the body, and especially perhaps upon the +<span class="pagenum">Page 52<a name="Page_52" id="Page_52"></a></span> +process of digestion, may find it hard to believe that these +distressing symptoms and profound changes in the aspect and nutrition +of the patients were due entirely to mental causes and were symptoms +in accord with the attempted suicide or the theft of the money. In +nervous little children we shall not often find such complex actions +as suicide or theft, although they do occur, but combined with other +evidence of nervousness we shall meet commonly enough with a +persistent setting aside of appetite and refusal of food and with +continuous and habitual vomiting, from nervous causes.</p> + +<p>The experiments of Pawlow and others have explained the dependence of +digestion upon mental states. They show that even before the food is +taken into the mouth, while the meal is still in prospect, there has +been instituted a series of changes in the wall of the stomach, which +gives rise to the so-called psychic secretion of gastric juice. These +changes are preceded by the sensation of appetite, which is evoked not +by the presence of food in the stomach—for the food has not yet been +swallowed—but by the anticipation of it, by the sight and smell of +food, as well as by more complex suggestions, such as the time of day, +the habitual hour, the approach of home, and so forth.</p> + +<p>Emotional states of all sorts—grief, anger, anxiety, or +excitement—put a stop to the process or interfere with its action, so +that the sense of appetite is absent, and the taking of food is apt to +be followed by discomfort or pain or vomiting. No doubt good digestion +leads to a placid mind, but it is +<span class="pagenum">Page 53<a name="Page_53" id="Page_53"></a></span> +equally true that a placid mind is +necessary for good digestion. Therefore we civilised people, living +lives of mental stress and strain, try to increase the suggestive +force of our surroundings and to provoke appetite by all devices +calculated to stimulate the æsthetic sense. The dinner hour is fixed +at a time when all work and, let us hope, all worry is at an end for +the day. The dinner-table is made as pretty as possible, with flowers +and sparkling glass. We are wise to dress for dinner, that with our +working clothes we may put off our working thoughts.</p> + +<p>In the treatment of adult dyspepsia we seldom succeed unless we can +place the mind at rest. We may advise a visit to the dentist and a set +of false teeth, or we may administer a variety of stomach tonics and +sedatives, but if the mind remains filled with nameless fears and +anxieties we shall not succeed.</p> + +<p>In adult life the nervous person when subjected to excessive stress +and strain is seldom free from dyspeptic symptoms of one sort or +another, and what is true of adult life is even more true of +childhood, when the emotions are more poignant and less controlled. +Then tears flow more readily than in later life, and tears are not the +only secretions which lie under the influence of strong emotion. +Emotional states, which would stamp a grown man as a profound +neurotic, are almost the rule in infancy and childhood, and may be +marked by the same physical disturbances—flushing, sweating, or +pallor, by the discharge of internal glandular secretions as well as +by inhibition of appetite, by vomiting, +<span class="pagenum">Page 54<a name="Page_54" id="Page_54"></a></span> +gastric discomfort, or +diarrhoea. Naturally enough, mothers and nurses are wont to demand a +concrete cause for the constant crying of a little child, and +teething, constipation, the painful passage of water, pain in the +head, or colic and indigestion are suggested in turn, and powders, +purges, or circumcision demanded. There can be no doubt that nervous +unrest is capable of producing prolonged dyspepsia in infancy and +childhood—a dyspepsia which, while it obstinately resists all +attempts to overcome it by manipulation of the diet, is very readily +amenable to treatment directed to quiet the nervous system.</p> + +<p>Where a primary dyspepsia exists for any length of time, the growth +and the nutrition of the child is clearly altered for the worse. The +character of the stools, their consistency, smell, and colour, is apt +to be changed because the bacterial context of the bowel has become +abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, +prolapse of the rectum, and infection with thread-worms are common +complications. No doubt children with primary dyspepsia are often +nervous and restless, and the elements of infection and of neurosis +are frequently combined. Yet often we meet with cases in which the +gastric or intestinal disturbance comes near to being a pure neurosis. +The nutrition, then, seldom suffers to any very great extent, or to a +degree in any way comparable to that which is characteristic of +dyspepsia from other causes. Emaciation, wrinkling of the skin, +dryness and falling out of the hair, decay of the teeth, are not as +<span class="pagenum">Page 55<a name="Page_55" id="Page_55"></a></span> +a rule part of the picture of nervous dyspepsia. The child may be slim +and thin and nervous looking, but as a rule he is active enough, with +a good colour and fair muscular tone, so that one has difficulty in +believing the mother's statements, which are yet true enough, as to +the trouble which is experienced in forcing him to eat, or as to the +frequency of vomiting.</p> + +<p>In early childhood the difficulty of the refusal of food often passes +or diminishes when the child learns to feed himself with precision and +certainty. To teach him to do so, it is not wise to devote all our +attention to making him adept at this particular task. The fault is +that the brain centres which control the movements of hands, mouth, +and tongue have not been developed, because his activities in all +directions have not been encouraged. It is much less trouble for a +nurse to feed a little child than to teach him to feed himself, and if +he is not given daily opportunities of practice he will certainly not +learn this particular action. But the fault as a rule lies deeper. The +child who cannot feed himself cannot be taught until fingers and brain +have been developed in the thousand activities of his daily routine, +by which he acquires general dexterity. A child who is still too young +to feed himself is learning the dexterity which is necessary as a +preliminary in every action of the day. If he can carry the tablecloth +and the cups and saucers to the tea-table, imitating in everything the +action of his nurse, it will be strange if he does not also imitate +her in the <span class="pagenum">Page 56<a name="Page_56" id="Page_56"></a></span> +central scene, the actual eating of the food. If, on the +other hand, he is waited upon hand and foot, if he is restrained and +confined, sitting too much passively, now in his perambulator, now in +his high chair, now on his nurse's lap, his imitative faculties and +his tactile dexterity alike remain undeveloped. The child who is slow +in learning to feed himself shows his backward development in every +movement of his body. One may note especially the stiff, +"expressionless" hands, indicating a general neuro-muscular defect. I +have seen many children of eighteen months or two years of age in whom +the movements necessary for efficient mastication and swallowing had +failed to develop satisfactorily. In some a pure sucking movement +persisted, so that when, for example, a morsel of bread or rusk was +put in the child's mouth, it would be held there for many minutes and +submitted only to suction with cheeks and tongue. Attempts to swallow +in such a case are so incoordinate that they give rise frequently to +violent fits of choking, which distress the child and produce +resistance and struggling, while at the same time they alarm the +mother or nurse so much that further attempts to encourage the taking +of solid food are hastily and for a long time abandoned. In this +helpless condition the other factors which tend to develop what we +have called negativism have full play. The want of imitation and the +lack of dexterity is not the sole or perhaps the main cause of the +child's refusal of food and of the apparent want of appetite, but it +is the cause of the failure to learn to feed himself, +<span class="pagenum">Page 57<a name="Page_57" id="Page_57"></a></span> +which places him in a condition which is peculiarly favourable to the operation of +other factors. If only we can teach the child to feed himself, the +difficulties of the situation become much less formidable.</p> + +<p>The first of the factors which encourage the persistent refusal of +food is the extreme susceptibility of the child to suggestion. A +particular article of diet may be refused on one occasion, perhaps in +pique, because another more favoured dish was hoped for or expected, +or perhaps because the taste is not yet familiar. Then if on this +occasion a struggle for the mastery is waged, and a painful impression +is made on the child's mind connecting this particular dish with +struggling and tears, from that day forward the child may persistently +refuse it on every occasion it is offered. Matters are made worse if +the nurse, anticipating refusal, attempts to overcome the resistance +by peremptory orders, or by excessive praise extolling the delicious +flavour with such fervour that the child's suspicions are at once +aroused. Previous experience has made him connect these excessive +praises with articles which have aroused his distaste. If these fads +and fancies on the part of the child are to be avoided, it is +essential that we should do nothing to focus his attention on his +refusal. It is better that his dinner should be curtailed on one +occasion than that taste and appetite should be perverted perhaps for +years. Every nurse or mother should cultivate an off-hand, detached +manner of feeding the child, and should patiently continue +<span class="pagenum">Page 58<a name="Page_58" id="Page_58"></a></span> +to offer the food without uncalled-for comments or exhortations. Let her always +remember the force of suggestion on the child's mind, and that a +confident manner which never questions the child's acceptance will +meet with acceptance, while a hesitating address, from fear of the +impending refusal, will be apt to meet with refusal. Sometimes a still +worse fault manifests itself, when nurse and mother speak before the +child of the smallness of his appetite, and of his persistent refusal +of this or that article of diet. The suggestion then acts still more +powerfully on his mind. He is aware that the whole household is +distressed by his peculiarity, and he grows to identify it with his +own individuality, and to regard himself with some satisfaction as +possessing this mark of distinction. If there is any difficulty of +this sort it is often directly curative to reverse the suggestion and +to speak before him of his improving appetite, and to say that he +begins every day to eat better and better, even if to do so we have to +break a good rule never to say to the child what is not strictly true. +Or once or twice we may take his plate away before he has finished, +saying positively that he has eaten so much that he must eat no more. +If in spite of every care antipathies to certain articles of food +appear and persist, we must be content to bide our time. When the +child grows of an age to reason, we should seize every opportunity to +make him feel that his persistent refusal is a little ridiculous and +childish. Little by little the seed is sown, and will germinate till +one day we shall note with surprise +<span class="pagenum">Page 59<a name="Page_59" id="Page_59"></a></span> +that he has taken of his own accord that which he has neglected +for so long and with such obstinacy.</p> + +<p>But the force which is acting most strongly in producing this refusal +of food is the force of which we have spoken in a previous +chapter—the force which results in negativism, the force which is in +reality the habit of opposition, the love of power, and the desire to +attract attention. Here again the refusal of food, if due to this +cause, is never the sole manifestation of the fault. Just as the delay +in learning to swallow and to chew properly and to feed himself is +part of a general want of dexterity and capacity manifested in all his +actions, so it will seldom happen that the child's anxiety to oppose +is only seen at meal-times. Watch a nervous child in the nursery +before the dinner hour. He is cross and restless and inclined to cry. +The nurse hands him a doll, and he throws it away saying, "No, no +doll." At the same moment he may catch sight of his ball, and it too +is violently rejected, "No, no ball." Everything in turn is treated in +the same way. Finally he falls upon his nurse, crying and beating her +with his hands, saying, "No, no Nurse." If that long-suffering woman +at that moment summons him to dinner, it will be strange indeed if his +attitude is not "No, no dinner," and "No, no" to every mouthful +offered him. How strong this love of opposition may be is illustrated +by the case of a little boy who was brought to me for refusal of food. +Three weeks before, he had been taken in a motor-car to his +grandfather's to midday dinner on Sunday, when his absolute refusal of +food had spoiled the +<span class="pagenum">Page 60<a name="Page_60" id="Page_60"></a></span> +day and had occupied the attention and the +efforts of the whole party. Doubtless he had enjoyed himself, for +three weeks later, when he caught sight of the car which was to bring +him to me, and which he had not seen in the interval, he at once said, +"Not eat my dinner." This child's father told me that the sight or +sound of the preparation of a meal was enough to bring on a paroxysm +of opposition. Now this force of opposition, as we have seen, only +develops into a serious difficulty when the child's own will has been +opposed too much, when authority has been too freely exercised, and +when the child has been urged and entreated and reproved with too +great frequency. His opposition grows with all counter-opposition. And +he is not really naughty, only irritable and restless from the +thwarting of his natural impulses, and unable to express his thoughts +and desires. Negativism will not often confine itself to meal-times. +It will show clearly in all the actions of the child, and to get him +to eat well and freely we must so change our management of him that +negativism disappears or at least diminishes. There is no other way. +No entreaty, no force, no threats of force will ever succeed, but will +only make him worse, and, since negativism is due to mental unrest, +the struggles and crying will only perpetuate the cause. The one way +to banish negativism and overcome the opposition is to cease to +oppose, and to practise this aloofness not so much at meal-times, for +somehow by patience the child must be got to take his food, but in all +our conduct to him. Repression and reproof, and +<span class="pagenum">Page 61<a name="Page_61" id="Page_61"></a></span> +thwarting of the child's will, and coaxing and entreaty must cease. There is no fear +that we shall thereby make the child unduly disobedient. We have +already, in another chapter, decided that negativism is not strength +of will on the part of the child which must be broken, but is the +result of constant attempts to oppose his nature, and the consequent +nervous unrest. If we cease to oppose, the symptoms will tend rapidly +to disappear, the child will become busy and contented and happy in +his play, and we shall hear no more of his refusal of food. If +sometimes it recurs for a week or two, we shall know how to deal with +it.</p> + +<p>In children, as with us, periods of nervous unrest and unhappiness are +apt to recur in a sort of cycle. This cyclical character of mental +disturbance is often a marked feature. We see it in epilepsy and +in what the French have called Folie Circulaire. We see it in the +dipsomaniac, in the intermittency of his craving for drink and of his +periodical outbursts, and we see it in ourselves in those periods of +depression which recur so often, we know not why. Little children too +sometimes get out on the wrong side of their beds, and never get right +the whole long day. Their own experience of the vagaries of mental +states should lead mothers to be indulgent to the children in their +days of cloud and to be particularly careful not to goad them by +well-intentioned efforts into bursts of naughtiness and passion, each +one of which tends to perpetuate the condition and increase the +nervous unrest. We know how closely dependent is the sensation of +<span class="pagenum">Page 62<a name="Page_62" id="Page_62"></a></span> +appetite upon emotional states, and we must do all in our power—and +the task is sometimes one of real difficulty—to keep the child's mind +sufficiently at rest to preserve the healthy desire for food +unimpaired. If there is no sign of appetite, but every sign of +restlessness and irritability, we must seek in the management of the +child until we find the fault.</p> + +<p>If food is taken mechanically and without appetite, if the preliminary +changes in the stomach wall which are necessary for adequate digestion +do not take place, but are inhibited by the mental unrest, the meal is +apt to be followed by gastric pain and discomfort, or, more commonly +with children, the stomach may promptly reject its contents. At the +worst, nervous vomiting of this sort may follow almost every meal, +although, again, it is curious to note how little, comparatively +speaking, the nutrition of the child suffers. The vomiting too, as in +adults, comes very near being a voluntary act, and mothers and nurses +will often remark that they get the impression that it can be +controlled at will. If once the diagnosis is made that the want of +appetite or the vomiting is of nervous origin, the treatment of the +condition is clear. Sedative drugs directed towards quieting the +nervous excitability may be of service, but tonics, appetisers, +laxatives, and drugs with a direct action on the stomach will have but +little effect. Nor is there as a rule anything to be gained by +modifying the diet or by excluding this or that article of food. The +frequency of the vomiting is such that it is apt to have brought +<span class="pagenum">Page 63<a name="Page_63" id="Page_63"></a></span> +discredit one after the other upon almost every article of food which +the child can take, with the result that many useful and necessary +foods have been abandoned for long on the ground that they are the +cause of the dyspepsia. A permanent cure will only be effected when +the faults of environment have been overcome, when the cause of the +nervous unrest has been removed, and when the child's mind is at +peace.</p> + +<p>Nervous vomiting of this kind is not difficult to control, if those in +charge of the children can be made to understand that the cause lies +in the anxiety which they themselves show before the child, increasing +his own apprehension or adding to his sense of power or importance. +Once the child is convinced that his conduct excites no particular +interest, the vomiting soon ceases. In more than one instance, +vomiting which has persisted for many months has stopped at once after +the matter has been fully explained to the parents. In the most +inveterate case of this sort which has come under my notice, the child +was regularly sick as soon as he caught sight of a white cloth being +laid on the table for meals. Yet even this child never vomited when he +was under the charge of a particular nurse who had to return more than +once to the family, and on each occasion was successful in breaking +the habit.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 64<a name="Page_64" id="Page_64"></a></span></p> + +<h3>CHAPTER IV</h3> + +<h3>WANT OF SLEEP</h3> + +<p> </p> +<p>So far, almost all that has been written—and there has been a great +deal of unavoidable repetition—has been devoted to an attempt to +determine the causes which lead the child to refuse food and the +methods which we adopt to prevent or overcome the difficulty. Other +neuroses may be studied in less detail, because they depend for their +existence upon the same causes. For example, the habit of refusing +sleep, which is as common and almost as distressing as the habit of +refusing food, depends both upon a perversion of suggestion and upon +the phenomenon that we have called negativism.</p> + +<p>If struggling and crying has occurred upon a series of nights, the +child comes to associate his bed not with sleep but with tears. If a +mother values her peace of mind, if she would spare herself the +discomfort of hearing her child sob himself nightly into uneasy sleep, +she must be wary how this all-important event of going to bed is +approached. With a nervous and restless child the preliminaries of +preparing for bed must be managed carefully and tactfully. The hour +before bedtime is almost +<span class="pagenum">Page 65<a name="Page_65" id="Page_65"></a></span> +universally the most interesting of the +whole day for the child. Then the baby, with his best frock on, and +books and toys, is the centre of interest in the drawing-room, till +the clock strikes and the nurse appears at the door. Suddenly it is +all over, and inexorable routine sends him off to bed. The good nurse +will give the child a little time to recover from the shock of her +arrival, and will not hurry him. She knows that his little mind is +slow to act, and that he must be led gradually to face a new prospect. +If she hurries him, catching him up in her arms from the midst of his +unfinished pursuits, resistance and tears are almost sure to follow, +and the difficult task of the day—the putting to bed—has made the +worst possible start. When this has happened on one or two successive +evenings, the habit of resistance to going to bed becomes fixed, and, +like all bad habits, is difficult to break. A nurse who has a way with +children will arouse his interest in a new pursuit, in which he can +play the chief part, the putting away of his picture books and toys. +If he is too small to carry his own chair or table to its allotted +place in the room, at least he can show his learning by pointing out +the spot. In the waving of good-byes he is expert and takes a +legitimate pride, and upstairs he has learnt that there are new +delights. He himself can turn on the taps in the bathroom, and he can +set every article in the proper place ready for use. All children love +their bath, and if interest and good temper has been so far preserved, +without a break, it will be ill-fortune if even the drying process is +not carried off <span class="pagenum">Page 66<a name="Page_66" id="Page_66"></a></span> +without a hitch. Afterwards, for a little, nervous +babies, whose brains still teem with all the excitements of the day, +are best left to sit for a few moments by the nursery fire, while the +nurse puts all the garments one by one to bed. Each as it goes to rest +will be greeted by him with cheerful farewells; and so does the force +of suggestion act, till the central figure himself plays his part in +the scene, of which he feels himself the controller and director, and +climbs to bed. But if there has been a hitch anywhere, if the bugbear +of negativism has appeared, if he has been scolded or coaxed or +repressed too much and there have been tears and struggles, then going +to bed is a poor preparation for instant and quiet sleep.</p> + +<p>With excitable, highly-strung children, the best laid plans and the +most tactful nurse will not always succeed, and to place him in his +cot is to provoke a storm of angry refusal and resistance. There are +mothers who believe that the best way is then to turn out the light +and leave the child to cry himself to sleep. This is a point on which +no one can lay down rules which are applicable for all children. It +may sometimes succeed, and the child may reason correctly and in the +way we wish him to reason, deciding that the game is not worth the +candle and so give it up. But with nervous, highly-strung children I +doubt if this Spartan conduct is commonly successful. Often if the +attempt is made, the troubled mother, listening to all these +heart-breaking sobs, can bear it no longer, and goes back to the side +of the cot to soothe and persuade +<span class="pagenum">Page 67<a name="Page_67" id="Page_67"></a></span> +him. Then certainly the longer she +has restrained her natural inclination, the longer the child has +sobbed himself into a pitiful little ball of perspiration and tears, +the more difficult will be her task in quieting him, the stronger will +be the impression formed on the child's mind, and the greater will be +the suggestion which will act under the same circumstances to-morrow. +Children who fall a prey to this uncontrolled crying, cry on because +they cannot stop when they have begun. They do not then cry purposely +or with a fixed intention, desiring to attain some object. They cry +because their minds are not at rest, but are irritated and overwrought +by the happenings of the day. We decided that it was useless to +attempt by exhortations at meal-times to induce a nervous child to eat +who habitually refuses food, and that we can only cure the condition +by eliminating from his daily life the elements of repression and +opposition which provoke the counter-opposition. And we must seek the +same solution in this other difficulty of the refusal of sleep. It is +useless to attempt to treat the symptom of refusal of sleep and to +leave the cause of that symptom still constantly in action.</p> + +<p>If, in spite of our care to avoid unrest and irritation of the child's +brain, sleep is refused, as may often happen, it is, as a rule, wise +to cut short the crying if we can, before a vicious circle has been +formed and the unrest has been intensified by the emotional storm. It +is useless with little children to urge them to go to sleep or to +coax. It is not usually wise to leave the child for a little and then +<span class="pagenum">Page 68<a name="Page_68" id="Page_68"></a></span> +to return. Each time the child is left, each time the mother or nurse +returns, the crying bursts forth again with renewed force and vigour. +It is at least one good plan with a little child to turn the light +out, and, treating the whole incident in the most matter-of-fact way +possible, lightly to stroke his head or pat his back rhythmically +without speaking. With older children, if the crying is more +purposeful and less emotional, the mother may busy herself for a +little with some task in the room, ostentatiously neglecting the storm +and making no reference to it. If she speaks to the child at all she +should do so in a matter-of-fact way, referring lightly to other +matters. If only she can convince him that his conduct is a matter of +indifference to her, the victory is won. It is because the child knows +so well that his mother does care that he so often has the upper hand. +It is not difficult to distinguish between a true emotional storm and +the tyrannous cry of a wilful child who demands his own way.</p> + +<p>Light and broken sleep is a common accompaniment of a too excitable +and overstimulated brain. The placid child, who eats well, plays +quietly, and does not cry more than is usual, as a rule sleeps so +soundly that no ordinary sounds, such as conversation carried on in +quiet tones in his neighbourhood, have the power to waken him. When he +wakes, he does so gradually, perhaps yawning and stretching himself. +The nervous child may move at the slightest sound, or with a sudden +start or cry is wide awake at once. A hard mattress should be +<span class="pagenum">Page 69<a name="Page_69" id="Page_69"></a></span> +chosen without a bolster, and with only a low pillow. Flannel pyjamas, which +cannot be thrown off in the restless movements of the child, should be +worn. The temperature of the room should be cool, and the air from the +open window should circulate freely, while draughts may be kept from +striking on the child by a screen. All the sensations of the nervous +child are abnormally acute. Thus, for example, an itching eruption, or +tight clothing, will produce an altogether disproportionate reaction, +and may result in a frenzy of opposition. Especially such a child is +sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool +rooms and warm but light and porous clothing are essential. An +electric torch, which can be flashed on the child for an instant, will +assist the mother or nurse to make sure that the child has not thrown +off all the bedclothing.</p> + +<p>Sometimes want of sleep is accounted for by a real want of physical +exercise. Town children especially are apt to suffer from their +limited opportunities of running freely in the open. It is often +considered enough that the child seated in his perambulator should +take the air for three or four hours daily, while much of his time +indoors as well is devoted to sitting. It is necessary for his proper +development that he should have opportunities of daily exercise in the +open. If for any reason this is not always practicable, a large room, +as free as possible from furniture, should be chosen, with windows +thrown wide open, in which the child may romp until he is tired.</p> + +<p><span class="pagenum">Page 70<a name="Page_70" id="Page_70"></a></span> +It is rare for children of two or of three years of age, whose case +we are now considering, to be troubled by bad dreams, nightmares, or +night-terrors. If these should occur, obstructed breathing due to +adenoid vegetations is sometimes at work as a contributory cause.</p> + +<p>Finally, we should always remember that refusal of sleep is, for the +most part, caused and kept up by harmful suggestions derived from +mother and nurse, who allow the child to perceive their distress and +agitation, who speak before the child of his habitual wakefulness, who +unwittingly focus his attention on the difficulty. It is cured in the +moment that the suggestion in the child's mind is reversed, in the +moment when he comes to regard it as characteristic of himself not to +make a fuss about going to bed, but to sleep with extraordinary +readiness and soundness. Let every one join together to produce this +effect. Let the suggestion act strongly on his mind that all these +troubles of sleeplessness are diminishing, that night after night sees +an improvement, and soon his reputation as a good sleeper will be +established, and, as always with children, it will be rigidly adhered +to.</p> + +<p>In assisting to break the habit of sleeplessness, and in the process +of altering the character of the suggestions which act on the child's +mind, we can be of the greatest assistance to the mother by +prescribing a suitable hypnotic. As to whether it is right in insomnia +in childhood to prescribe depressant drugs is a question on which very +various opinions are held. That it is wrong and +<span class="pagenum">Page 71<a name="Page_71" id="Page_71"></a></span> +probably ineffective to trust entirely to the drugs is certainly true, but as a +temporary measure, to break the faulty suggestion and the bad habit, their use +is both legitimate and successful. The dose required in children +relatively to the adult is much smaller. In grown people, some +specific distress of mind, whether real or imaginary, may suffice to +resist very large doses of hypnotic. In children it is rare to find +the same resistance, and comparatively small doses have a very +constant effect. With deeper and more refreshing sleep, the conduct of +the child during the day almost always changes for the better. A sound +sleep, for a few nights in succession, will produce apparently quite a +remarkable change in the whole disposition of the child. When good +temper and interest take the place of fretfulness and restlessness, we +may confidently expect that the symptom of sleeplessness will begin to +abate. Sleeplessness by night and fretfulness by day form a vicious +circle, and attempts must be made to break it at all points.</p> + +<p>Chloral occupies the first place as a hypnotic for young children. In +combination with bromide its effects are wonderfully constant and +certain. Two grains of chloral hydrate and two grains of potassium +bromide with ten minims of syrup of orange, given just before bedtime, +will bring sound sleep to a child of a year old. At three years the +dose may be twice as great, and three times at six years. It is seldom +that other means are required. Aspirin for children seems relatively +without effect. For children who are both sleepless and feverish, +<span class="pagenum">Page 72<a name="Page_72" id="Page_72"></a></span> +a grain of Dover's powder, and a grain of antipyrin, for each year of +the child's age up to three, is very helpful. Lastly, if chloral and +bromide cannot break the insomnia, and the condition of the child is +becoming distressing, we can almost always succeed if we combine the +prescription with an ordinary hot pack for twenty minutes.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 73<a name="Page_73" id="Page_73"></a></span></p> + +<h3>CHAPTER V</h3> + +<h3>SOME OTHER SIGNS OF NERVOUSNESS</h3> + +<p class="subhead">Habit Spasm</p> + +<p>Next to refusal of food and refusal of sleep perhaps the most frequent +manifestation of nervous unrest is provided by the group of symptoms +which we may call, with a certain latitude of expression, Habit +Spasms. By a habit spasm is meant the constant repetition of an action +which was originally designed to produce some one definite result, but +which has become involuntary, habitual, and separated from its +original meaning. The nervous cough forms a good example of a habit +spasm. A cough may lose its purpose and persist only as a bad habit, +especially in moments of nervousness, as in talking to strangers, in +entering a room, or at the moment of saying "How do you do" or +"Good-bye." Twitching the mouth, swallowing, elongating the upper lip, +biting the lips, wrinkling the forehead so strongly that the whole +scalp may be put into movement, and blepharospasm are all common +tricks of little children which may become habitual and uncontrolled. +In worse cases there may be constant jerking movements of the head, +nodding movements, or even bowing salaam-like movements. In mild +<span class="pagenum">Page 74<a name="Page_74" id="Page_74"></a></span> +cases we may note hardly more than a restless movement of mouth or +forehead, or constant plucking or writhing of the fingers whenever the +child's attention is aroused, when he is spoken to, or when he himself +speaks. In nervous children these movements, which should properly be +confined to moments of real emotional stress, become habitual, and are +displayed apart from the excitement of particular emotions. Whatever +their intensity, habitual and involuntary movements of this nature +should not be overlooked, and should be regarded as evidence of mental +unrest. They do not commonly appear during the first or second years +of the child's life. They are more frequent after the age of five, but +they may begin to be marked as early as the third year. With refusal +of food and refusal of sleep they form the three common neuroses of +early childhood.</p> + +<p>Two of the three qualities which we have mentioned as characteristic +of the child's mind are concerned in the causation of habit spasm. In +the early stages the movement is sometimes due to imitation, but the +susceptibility of the child to suggestion plays the chief part in +determining its persistence. It is an interesting speculation how far +tricks of gesture, attitude, or gait are inherited and how far they +are acquired by imitation. A child by some characteristic gesture may +strikingly call to mind a parent who died in his infancy. A whole +family may show a peculiarity of gait which is at once recognisable. +It is told of the son of a famous man, who shared with his father the distinctive +<span class="pagenum">Page 75<a name="Page_75" id="Page_75"></a></span> +family gait, that when a boy his ears were once boxed by +an old gentleman who chanced to observe him hurrying to overtake his +parent, and who resented what he took to be an act of impertinent +caricature. In the reproduction by the child of the habitual actions +of his parents, heredity is largely concerned, but imitation too plays +its part. In habit spasm the force of imitation is clearly seen. A +child who has developed a habit spasm of one sort or another will +readily serve as a model to other children. The malady will sometimes +spread through a school almost with the force of a contagious +disorder. A child affected in this way may prove an unwelcome guest. +The little visitor with a trick of contorting his mouth and grimacing +is apt to leave his small host an expert in faithfully reproducing the +action. A cough that is genuine enough in one member of the family may +produce a crop of counterfeits in brothers and sisters.</p> + +<p>The force of suggestion acting upon the child's mind can clearly be +traced. Once his attention is focused upon the particular movement by +unwise emphasis on the part of the parents, he loses the power to +control its occurrence. This trio of common neuroses—refusal of food, +refusal of sleep, and habitual involuntary movement—grows only in an +atmosphere of unrest and apprehension. Parents and nurses anxiously +watch their development. They are distressed beyond measure to note +their steady growth in spite of every attempt which they make to +control or forbid them. And of all this unrest and unhappiness the +child is acutely conscious. +<span class="pagenum">Page 76<a name="Page_76" id="Page_76"></a></span> +The whole household may become obsessed +with the misfortune which has befallen it, and the mother, losing all +sense of proportion, feels that she cannot regain her peace of mind +until it has been overcome. The child is in need of mental and moral +support from those around him, and all that he finds is an openly +expressed apprehension and sense of impotence. Even grown-up people, +when their nerves are on edge, are apt to be obsessed by +uncontrollable impulses or by vague and nameless apprehensions, and +surely all have learnt the support they gain from contact and +conversation with some one strong and sane, who treats their worries +in such a matter-of-fact way that immediately they lose their power +and become of no account. The child with habit spasm cannot control +these movements. The more he is reproved or entreated, the less able +does he find himself to hold them in check. He does not wish them to +continue. He has lost control of what he once controlled, and the +realisation of this is not pleasant, and may be alarming to him. Yet +when unconsciously he looks to his mother for support, he finds in her +open dismay that which serves only to increase his uneasiness. She +must subdue her own feelings and give the child strength. If she +treats the whole thing in a matter-of-fact way, as a temporary +disturbance which is of no importance in itself, and only has meaning +because it implies that the brain has been over-stimulated, she will +no longer exercise a prejudicial effect on the child. If the bad habit +is taken as a matter of course, if too much is not made +<span class="pagenum">Page 77<a name="Page_77" id="Page_77"></a></span> +of it, if the child is encouraged to think that nobody cares much about it at all, +then recovery will soon take place. It goes without saying that habit +spasms and tics of all sorts are made worse by excessive emotional +display and by nervous fatigue. On the other hand, if the child +becomes absorbed in some interesting occupation, the movements will +disappear for the time being.</p> + + +<p class="subhead">Air Swallowing, Thigh Rubbing, Thumb Sucking</p> + +<p>At a somewhat earlier age than that in which habit spasms become +common, and before bed wetting appears as a formidable difficulty, we +meet with another group of habitual actions which yet retain their +voluntary character. Among such habitual actions are thumb sucking, +thigh rubbing, and air swallowing. If the child is old enough to +express himself on the subject, he will explain that these actions are +performed because of the satisfaction derived from them, because it is +"comfy" and "nice." Even if the child is too small to speak, the +expression is that of beatitude and content. These actions are not +confined to nervous children, and their occasional practice need not +be taken to imply that there is any strong element of nervous +overstrain. It is only when the action is repeated with great +frequency and persistence, and when signs of irritation ensue if +gratification is not obtained, that we are justified in classing it +among the symptoms of mental unrest.</p> + +<p><span class="pagenum">Page 78<a name="Page_78" id="Page_78"></a></span> +The second of these actions, thigh rubbing, is found for the most +part in little girls, and inasmuch as it consists of a stimulation of +the sexual organs sometimes causes much distress to the parents. It is +in reality a habit of small importance unless exercised with very +great frequency. It is, of course, not associated in the child's mind +with any sexual ideas, and is of precisely the same significance as +the other two actions of the same class. Children who can speak will +refer to it openly without any sense of shame. As a rule the action is +performed in a half-dream state, that condition between sleeping and +waking which is found when the child is lying in the morning in her +cot or in her perambulator after the midday nap. The child's attention +should not be focused on the symptom. She should lie on a hard +mattress, and when she wakes in the morning she should either leave +her cot at once or she should be roused into complete wakefulness by +encouraging her to play with her toys. Little children should be +taught to sleep with their hands folded and placed beside the cheek. +If the movement occurs on going to sleep, it is best left alone and +completely neglected. As a rule each child has his or her own +favourite action of this class, and they are seldom combined in the +same child. If thigh rubbing is very constant and obstinate and does +not yield to the measures suggested, it may even sometimes be a +successful manoeuvre to substitute the thumb-sucking habit in the +expectation that this less distressing habit may eject the other more +objectionable action. +<span class="pagenum">Page 79<a name="Page_79" id="Page_79"></a></span> +As a rule, however, a wise neglect and careful +watching during the drowsy condition that follows sleep in a warm bed +will succeed in stopping the practice of thigh rubbing before the end +of the second or third year. Apparatus designed to restrain movement +of the child's legs or blistering the opposed surfaces of the thighs +are both of no effect. They have indeed the positive disadvantage that +they focus the child's attention on the practice. The habit ceases +only when the child has forgotten all about it, and these devices +serve only to keep it in remembrance. The same may be said of any +system of punishments. Further, we cannot always have the child under +observation, and at some time or other opportunity will be found for +gratification. Of older children, in whom self-control and a sense of +honour can be cultivated, I am not here speaking.</p> + +<p>Air swallowing is less common than thigh rubbing, but belongs to the +same group of actions and takes place in the same drowsy condition. +The child will rapidly gulp down air which distends the stomach, and +is then regurgitated with a loud sound. Thumb sucking seldom +distresses the mother to the same extent, and the proper attitude of +tolerance is adopted towards it. If much is made of it, it is +astonishing how persistent the habit may become, surviving all +attempts to forbid it, to break it by rewards or punishments, or to +render it distasteful by the application of a variety of ill-tasting +substances smeared on the offending digit. +<span class="pagenum">Page 80<a name="Page_80" id="Page_80"></a></span></p> + +<p class="subhead">Pica and Dirt Eating</p> + +<p>Certain other bad habits will become ingrained if attention is called +to them, because of that curious spirit of opposition which +characterises little children, and because of their susceptibility to +suggestion. Some children will constantly pluck out hairs and eat +them, or will devour particles of fluff drawn from the blankets. +Others will seize every opportunity to eat unpleasant things, such as +earth, sand, mud, or dirt of any sort. All tricks of this sort are +best neglected and treated by attracting the child's attention to +other things. In adult life they are associated with serious mental +disturbance, in early childhood they are of little account, or at most +suggest a certain nervousness which may be due to nervous irritation +from faults of management which we must strive to correct.</p> + + +<p class="subhead">Constipation</p> + +<p>As has been already mentioned, much of the common constipation of the +nursery is due to neurosis. The excessive concentration of the nurse's +thoughts on this daily question communicates itself to the child. The +difficulty is emphasised, and an attempt is made to substitute will +power for forces of suggestion which are at once inhibited by +concentration of the mind upon the process. Here also, just as in the +refusal of food, a further stage of "negativism," that is, of active +resistance with crying and struggling, is reached, so that complaint +<span class="pagenum">Page 81<a name="Page_81" id="Page_81"></a></span> +may be made by the mother that defæcation is painful. The same +negativism may be shown in micturition, and mothers will give +distressing accounts of the suffering of the child during the passing +of water.</p> + + +<p class="subhead">Breath-Holding and Laryngismus Stridulus</p> + +<p>In some children, in the first two years of life, we find a definite +and measurable increase in the irritability and conductivity of the +peripheral nerves. The strength of current necessary to produce by +direct stimulation of the nerve a minimal twitch of the corresponding +muscle may be many times less than the normal. Of this heightened +irritability of the nervous system, to which the name "spasmophilia" +has been given in America and on the Continent, the most striking +symptom is a liability alike to tetany or carpo-pedal spasm, to +generalised convulsions, and to laryngismus stridulus. In addition, in +most cases it is generally possible to demonstrate the presence of +Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a +visible twitch of the facial musculature, especially of the +orbicularis palpebrarum or of the orbicularis oris, in response to a +gentle tap administered over the facial nerve in front of the ear. +Trousseau's sign is the production of tetany by applying firm and +prolonged pressure to the brachial nerve in the upper arm. The +ætiology of spasmophilia is still a matter for dispute, but the +evidence which we possess is in favour of the view that we +<span class="pagenum">Page 82<a name="Page_82" id="Page_82"></a></span> +have here to deal with a disturbance of calcium metabolism. The calcium content +both of the blood and of the central nervous system has been shown to +be much lowered. It is in keeping with this that clinically we note +how frequently spasmophilia and rickets occur in the same child. In +some families the condition recurs through many generations.</p> + +<p>For our present purpose—the examination of some common neuroses of +nursery life—it would be out of place to enter into a detailed +consideration of this disorder of spasmophilia as a whole. The symptom +of laryngismus stridulus—the so-called breath-holding—alone need +concern us, and that for a special reason. The spasm of the glottis is +produced under the influence of any strong emotion—in anger, for +example, or in fear, in excitement or in crying for any reason. To +control or prevent it we must direct attention not only to the +condition of spasmophilia, but also to the management of the children +who are always excitable and emotional. In these children every burst +of crying, however produced, whether by a fall, by a fright, by the +entrance of a stranger, or by a visit to a doctor, is apt to be +ushered in by a long period of apnœa, due to spasm of the glottis +and of the diaphragm. The first few expirations are not followed by +any inspiration. For several seconds the silence may be complete, +while the child steadily becomes more and more cyanosed, or the body +may be shaken by incomplete expiratory movements and strangled cries +which are suppressed because the chest is already in a position of +almost complete expiration. +<span class="pagenum">Page 83<a name="Page_83" id="Page_83"></a></span> +In the worst cases, when the apnœa +lasts a very long time, there may be convulsive twitching of the +muscles of the face, or the attack may even terminate in general +convulsions. Very occasionally the spasm is actually fatal. In all +fatal cases which have come to my notice the child at the moment of +death had been alone in the room. I have met with no fatal case where +the baby could be picked up and assisted. As a rule, therefore, the +cause and mode of death must be conjectural, but when an infant is +found dead in its cot unexpectedly, it would seem likely that it has +waked from sleep with a sudden start, become excited, and, about to +cry, has been seized by the fatal spasm. In two instances reported to +me a cat had been found in the room with the dead child, and it was +suggested that the animal had lain upon the child's face. Both these +children, however, were vigorous and capable of powerful movements of +resistance. I think it more likely that the cat may have awakened them +in fright, and that the emotional excitement, giving rise to the +spasm, was the cause of the suffocation. That the apnœa in these +extremely rare instances should end fatally produces a difficult +position for the doctor. It need hardly be said that the seizures are +alarming to the parents. For the sake of great accuracy in the +statement of our prognosis are we to add a hundred times to the +mother's alarm by stating the possibility of death? In each case we +must use our own judgment. I believe that in a child over a year old +the risk is almost negligible.</p> + +<p><span class="pagenum">Page 84<a name="Page_84" id="Page_84"></a></span> +Fortunately in all save the rarest possible instances the apnœa +yields and a deep inspiratory movement follows. As the air rushes past +the glottis, which is still partially closed, a sound recalling the +whoop of pertussis is heard. Often this recurs throughout all the +burst of crying which follows, and each inspiration is accompanied by +a shrill stridulous sound. With the re-establishment of respiration +the cyanosis rapidly fades, to be succeeded in some cases by pallor +and perspiration.</p> + +<p>It need hardly be said that we should do all in our power to prevent +these alarming and distressing attacks. Each seizure predisposes to a +repetition. In some children we notice that months and even years +after an attack of whooping-cough, a slight bronchial catarrh may be +sufficient to bring back the characteristic cough. In laryngismus in +the same way we may suppose that the reflex path is made easy and the +resistance lowered by constant use. Fortunately the spasms are not +usually difficult to control. Calcium bromide, in doses of from two to +four grains, according to age, three times daily, is generally +successful with or without the addition of chloral hydrate in small +doses. At the same time we must endeavour in every way possible to +keep the child calm, by paying close attention to nursery management. +The child with spasmophilia is as a rule excitable and easily upset, +and although calcium bromide is a drug which offers powerful aid it is +not able to achieve its effect unless we are able at the same time to +guarantee a reasonable immunity from emotional upsets. It is for this +<span class="pagenum">Page 85<a name="Page_85" id="Page_85"></a></span> +reason that I have included some description of laryngismus, although +its origin is undoubtedly very different from that of the other +disorders of conduct which we have examined.</p> + + +<p class="subhead">Migraine and Cyclic Vomiting</p> + +<p>The ætiology of cyclic or periodic vomiting in childhood is not yet +completely understood. We do not know how far it is dependent upon +disturbance of the liver, and it is still disputed whether the +acidosis which accompanies it is the cause or the result of the +profuse vomiting. Into these difficult questions we need not at the +moment enter. It is enough in the present connection to recognise that +the great majority of children who suffer from cyclic vomiting are +sensitive, excitable, and nervous, and that every one is agreed that +the nervous system is intimately concerned in its causation.</p> + +<p>A close association between cyclic vomiting in children and that form +of periodic headache known as migraine has often been observed. It is +sometimes found that one or both parents of a child with cyclic +vomiting suffer habitually from migraine. In a few instances the one +condition has been observed to be gradually replaced by the other, the +child with cyclic vomiting becoming in adult life a sufferer from +migraine. There is indeed much which is common to the two conditions. +The periodic nature of the seizure, often following a time when the +general health and vigour appear to have been at their optimum, the +extreme prostration, <span class="pagenum">Page 86<a name="Page_86" id="Page_86"></a></span> +and the comparatively sudden recovery are found +in both. In the cyclic vomiting of children, it is true, little +complaint is made of headache, the visual aura is absent, and the +vomiting is invariably the most prominent symptom.</p> + +<p>Cyclic vomiting seldom occurs before the fourth year. It is +characterised by sudden profuse and persistent vomiting and by very +great prostration. All food, it may be even water, is promptly +rejected. The vomited matter is generally stained with bile; +occasionally the violence of the vomiting causes hæmatemesis. In many +cases the temperature is raised; sometimes it may be as high as 103° +F. The duration of an attack varies. In most cases it does not last +longer than forty-eight hours. On the other hand, attacks lasting as +long as a week are by no means unknown. Within a short time of the +onset the urine may be found to contain acetone bodies, the breath may +smell distinctly of acetone, and the child may become torpid and +drowsy or agitated and restless. At times there may be exaggerated and +deepened respiratory movements—the so-called air hunger. In many +cases, however, otherwise characteristic, these more severe +manifestations are absent or but little apparent. Recovery is usually +rapid and complete. The child asks for food, which is retained. A +fatal ending is very rare, though not unknown. The frequency of +attacks is very various. Sometimes months or even years may elapse +between successive seizures; in other cases a fortnightly or monthly +rhythm establishes itself.</p> + +<p><span class="pagenum">Page 87<a name="Page_87" id="Page_87"></a></span> +It is clear that both the frequency and the severity of the attacks +are much influenced by the general state of the child's health. Like +migraine, cyclic vomiting appears to be a symptom of nervous +exhaustion. It affects, for the most part, children who are +intellectually alert, impressionable, and forward for their age, and +who, when well, throw themselves into work or play with a great +expenditure of nervous energy. Often their physical development is +unsatisfactory, and we must set ourselves to correct this as the first +step in prevention. It is highly important that children suffering in +this way should have free opportunities for exercise in the open +country, and that all the excretory organs—the skin, kidneys, and +bowels—should be acting freely and efficiently. The child should live +a life of ordered routine. Sleep should be sound and sufficient in +amount. The diet must not exceed the strict physiological needs. Many +of these children appear to have a lowered tolerance for fats of all +sorts, and it may be necessary to limit strictly the consumption of +milk, cream, butter, and so forth. A daily administration of a small +dose of alkali by the mouth is credited with preventing attacks. In +the present connection, however, we shall not do wrong to emphasise +the part played by the nervous system in the production of the +attacks. In all cases of cyclic vomiting it should be our endeavour to +recognise and remove the elements in the daily life of the child which +are proving too exhausting. +<span class="pagenum">Page 88<a name="Page_88" id="Page_88"></a></span></p> + +<p class="subhead">Unexplained Pyrexia</p> + +<p>In nervous children we sometimes meet with inexplicable rises of +temperature. The pyrexia may have the same periodic character as that +just noted in cases of cyclic vomiting. At intervals of three, four, +or five weeks there may be a rise of temperature to 103° F., or even +higher, which may last for two or three days before subsiding. In +other cases the chart shows a slight persistent rise over many weeks +or months. That in nervous children the temperature may be very +considerably elevated without our being able to detect much that is +amiss does not of course make it any the less necessary to be careful +to exclude organic disease. Pyelitis, tuberculosis, and latent otitis +media occur with nervous children as with others and must not be +overlooked. If, however, organic disease can be excluded, and if the +pyrexia is the only circumstance which prevents the decision that the +child is well and should be treated as well, then the thermometer may +be overruled and the pyrexia neglected.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 89<a name="Page_89" id="Page_89"></a></span></p> + +<h3>CHAPTER VI</h3> + +<h3>ENURESIS</h3> +<p> </p> + +<p>I have dealt in previous chapters with certain common disorders of +conduct in childhood, which show clearly their origin in the +apprehensions of the grown-up people who have charge of the children, +and in the unwise suggestions which they convey to them. The same +forces are at work in the production of enuresis, or bed wetting, +although the matter is here often complicated by the development later +on of a sense of shame and unhappiness in the child. There comes a +time when the child passionately desires to regain control and is +miserable about her failure, until the concentration of her thoughts +on the subject becomes a veritable obsession. Every night she goes to +bed with this only in her mind. Every night she falls asleep, +miserably aware that she will wake to find the bed wetted. The +suggestion impressed in the first place on the mind of the tiny child +by injudicious management has become fixed by the growing sense of +shame and the complete loss of self-confidence.</p> + +<p>It is usually taught that a great variety of causes is concerned in +producing enuresis. It is said to be due to a partial asphyxia during +sleep from +<span class="pagenum">Page 90<a name="Page_90" id="Page_90"></a></span> +adenoid vegetation. It is said to be caused by phimosis, +and to be cured by circumcision. It is said that the urine is often +too acid and so irritating that the bladder refuses to retain it for +the usual length of time. It is said that enuresis may be due to a +deficiency of the thyroid secretion, and that it can be cured by +thyroid extract. Such a number of rival causes may make us hesitate to +accept the claims of any one of them. Certainly I have not been able +to satisfy myself that any one of these conditions exercises any +influence at all or is commonly present in cases of enuresis. I think +that if we examine a large number of cases of bed wetting in children +we can come to no other conclusion than that the cause of the trouble +is due to just such a pervasion of suggestion as we have been +considering above.</p> + +<p>There are certain points in the behaviour of a child with enuresis +which seem to point to this conclusion.</p> + +<p><i>(a)</i> In the first place, the trouble is seldom serious or very well +developed in early childhood, and the reason for this, I take it, is +that an occasional lapse in a child of perhaps two or three years of +age is usually treated lightly and in the proper spirit of tolerance. +It is only with children a little older that nurses and parents become +distressed and begin unwittingly by urging the child to present the +suggestion to her mind, that the bed may or will be wetted. Hence the +usual history is that control was partially acquired in the second +year, but that, instead of later becoming complete, relapses +<span class="pagenum">Page 91<a name="Page_91" id="Page_91"></a></span> +began to be more frequent, and that since that time all that can be done seems +only to make matters worse.</p> + +<p><i>(b)</i> In the second place, the influence of suggestion is shown by the +behaviour of the child when removed to a hospital for observation. It +is the invariable experience that the enuresis then promptly stops. In +hospital the attitude of those around the child is entirely different. +She has the comfortable and consoling feeling that in wetting the bed +she is doing exactly what is expected of her. There is even a feeling +that otherwise she is showing herself to be something of a fraud, and +that she has then been admitted to the hospital on false pretences. +Hence, perhaps for the first time in many years, the child is free +from the obsession, and the bed is not wetted.</p> + +<p><i>(c)</i> In the third place, it is easy to recognise in the history of +many of the cases, the ill-effects of circumstances which add new +force to the fear of failure or shake the confidence in the control +which had been regained. Thus a boy, an only child, who had suffered +from enuresis till his seventh year, had regained complete control +till his eleventh year, when he went to school. In his dormitory at +school was a boy who had enuresis, and who was being fined and +punished by the schoolmaster. The enuresis at once reappeared and +continued unchecked so long as he was at school. As might be expected, +school life is very inimical to cure, unless the trouble can be kept +from the knowledge of the other boys. Anything which directly +<span class="pagenum">Page 92<a name="Page_92" id="Page_92"></a></span> +increases the nervousness of the child—an illness, for example, with +loss of weight and failure of nutrition, or some mental stress, such +as the approach of an examination—is apt to accentuate the enuresis.</p> + +<p><i>(d)</i> In the fourth place, the incontinence sometimes spreads to the +daytime, and the child is wet both by day and night. Further, in bad +cases it is not uncommon to find incontinence of fæces making its +appearance also. These extensions of the fault only take place when +the management continues to be very faulty, when the grown-up people +around them are more than usually distressed and pessimistic, and have +redoubled their expostulations and appeals.</p> + +<p>Now these peculiarities of enuresis seem to me only explicable if we +assume that the want of control is due to auto-suggestion, dependent +at the beginning on the unwise attitude adopted towards the fault by +the nurses and parents, and later kept up by the sense of shame and +the mental distress involved.</p> + +<p>The forms of treatment which have been recommended from time to time +are, as might be expected, very numerous.</p> + +<p><i>(a) Operative.</i>—(i) Removal of tonsils and adenoids, (ii) +Circumcision.</p> + +<p><i>(b) Manipulative.</i>—(i) Injection of saline solution under the skin +in the perineal and pubic regions, with object of lowering the +excitability of the bladder by counter-irritation. (ii) Gradual +distension of the bladder by hydrostatic pressure, (iii) Tilting the +foot of the bed so as to throw the +<span class="pagenum">Page 93<a name="Page_93" id="Page_93"></a></span> +urine to the fundus of the +bladder, in order to protect the sensitive trigone from irritation.</p> + +<p><i>(c) Educative.</i>—(i) Curtailing the fluid drunk. (ii) Waking the +child at intervals during the night by an alarm clock or otherwise. +(iii) Rewards and punishments.</p> + +<p><i>(d) Medicinal.</i>—(i) Belladonna. (ii) Thyroid extract.</p> + +<p><i>(e) By Suggestion.</i>—(i) By simple suggestion. (ii) By hypnotic +suggestion.</p> + +<p>I do not think that any single one of these various forms of treatment +outlined under the first four heads has any effect other than to aid +the suggestion of cure which we proffer in adopting it. Removal of +tonsils and adenoid vegetations might conceivably cure an enuresis +which is nocturnal, it cannot account for an incontinence which +spreads to the day. We might believe that to distend the bladder by +hydrostatic pressure was a cure for incontinence of urine, and that it +acted by removing the local cause,—the smallness and contraction of +the bladder,—were it not that the loss of control is so apt to spread +to the rectum as well. There is no evidence that the urine is +peculiarly irritating. Indeed, such evidence as we have goes to show +that, as in some other neuroses, the urine in enuresis is unduly +copious, and of very low specific gravity. Incidentally, we have in +this polyuria a further argument against the view recently advanced +that a small and contracted irritable bladder is the cause of +enuresis. We do, of course, meet with cases of irritable bladder often +enough, but the complaint is +<span class="pagenum">Page 94<a name="Page_94" id="Page_94"></a></span> +then not of incontinence, but always of +the discomfort of having to rise so frequently for micturition.</p> + +<p>To deprive the child of fluid, to wake her many times at night, to +tilt the foot of the bed, are devices which may help in the hands of +some one who is confident of his ability to cure the condition and can +communicate the confidence to the child. Carried out hopelessly and +pessimistically by a tired and exasperated mother, they are well +calculated to strengthen the hold which the obsession has on the +child, so that often we meet with a mother who rightly enough +maintains that the more she wakes the child, the oftener the bed is +wet, till she wonders where it all comes from.</p> + +<p>The treatment of enuresis to be successful must be conducted through +and by means of the grown-up persons who have the control of the +children. To stop the development of enuresis in early infancy we must +intervene to prevent the concentration of the child's mind on the +difficulty. During the time when control is ordinarily developed, in +the second and third year, judicious management of the child is +essential. The emphasis should be laid upon successes, not upon +failures. For every child his reputation will sway in the balance for +a time. He must be helped and encouraged to self-confidence, not +rendered diffident or self-conscious.</p> + +<p>If the case is well established before it comes under our notice, the +mother, the nurse, the schoolmaster, or whoever is responsible for the +child's management, must understand clearly the nature of the trouble. +The suggestion acting on the +<span class="pagenum">Page 95<a name="Page_95" id="Page_95"></a></span> +child's mind must be altered, and +self-confidence restored. The child must learn to see that the thing +is not so desperately tragic. He should be told that the trouble +always gets well, and that it only goes on now because he is worried +about it and keeps thinking of it. If the whole environment of the +child is bad, so that such a change of suggestion is not possible, and +if enuresis is but one of many symptoms of mental or moral +instability, it may be necessary to remove the child and place him +under the influence of some one else. Sometimes the prescription of a +rubber urinal, which the child can slip on at night, is directly +curative. A public school boy, who was about to be sent away from +school for this failing, fortified by the possession of this +apparatus, wrote six months later to say that he knew now that it must +be all worry that caused the trouble, because with the urinal in +position he had not once had the incontinence.</p> + +<p>In inveterate cases hypnotic suggestion is always, I think, +successful. It is obvious, however, that in many cases there are +objections to its use. Often enuresis is evidence that the child's +home environment has been at fault, and that his mental and moral +development has been retarded. It is the management which must be +modified or the home, if necessary, changed. Hypnotic suggestion will +make this one symptom disappear promptly enough, but it will rather +perpetuate than combat the cause—that undue susceptibility to +suggestion, which is characteristic alike of the little child and of +many older neuropathic persons.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 96<a name="Page_96" id="Page_96"></a></span></p> + + +<h3>CHAPTER VII</h3> + +<h3>TOYS, BOOKS, AND AMUSEMENTS</h3> +<p> </p> + +<p>Any one who has an opportunity of watching little children must have +observed that they are happiest and most contented when playing alone. +The education of the little child is carried on by means of games and +toys. Handling the various objects which we give him, imparting +movement to them, transferring them from hand to hand and from one +situation to another, he learns dexterity and precision of movement, +and in the process hand and brain grow in power. When at play, his +whole energies should be absorbed to the exclusion of everything else. +He will often be oblivious to everything that is going on around him, +intent only on the purpose of the moment. In order to permit this +fervour of self-education it is necessary that the child should be +accustomed to playing alone, and it is well, if only for convenience' +sake, that he should be accustomed to playing in a room by himself. +Something is wrong if the child cannot be left for a few moments +without breaking into tears or displaying bad temper. Engrossed in his +own tasks, he should be content to leave his nurse to move in and out +of the room without +<span class="pagenum">Page 97<a name="Page_97" id="Page_97"></a></span> +protest. If this fault has appeared and the child +cannot be left alone, our whole educational system is undermined, and +play will be profitless and over-exciting, because it demands the +constant participation of grown-up people. As a preliminary to all +improvement in the management of a nervous child, we must see to it +that he becomes accustomed to being alone. We must so arrange his +nursery that he can do no damage to himself. Scissors and matches must +not be left lying about, and a fireguard must be fixed in position so +that it cannot be disturbed. Then, disregarding his protests, the +nurse must leave him to himself, at first only for a moment or two, +re-entering the room in a matter-of-fact way without speaking to him, +and again leaving it. Soon he will learn that a temporary separation +does not mean that we have abandoned him for all time. Then the period +of absence can be gradually lengthened till all difficulty disappears. +Once his attention is removed from the grown-up people who mean so +much to him, his natural impulse to explore and experiment with his +playthings will show itself. Those toys are best which are neither +elaborate nor expensive. For a little child a small box containing a +miscellaneous collection of wooden or metal objects, none of them +small enough to be in danger of being swallowed, forms the material +for which his soul craves. Everything else in the room may be out of +his reach. A dozen times he will empty the box and then replace each +object in turn. He will arrange them in every possible combination, +and then sweep the whole away to start afresh.</p> + +<p><span class="pagenum">Page 98<a name="Page_98" id="Page_98"></a></span> +At eighteen months of age observation and imitative capacity will +have made more complex pursuits possible. As a rule the objects which +are most prized and which have most educative value are those which +lend themselves best to the actions with which alone the child is +familiar. Hence the supreme importance of the doll and the doll's +perambulator. The doll will be treated exactly as the child is treated +by the nurse. It will be washed, and dressed, and weighed, and put to +bed in faithful reproduction of what the child has daily experienced. +Dusting, and sweeping, and laying the table will be exactly copied. If +a child has no opportunity of being familiar with horses, if he has +not seen them fed, and watered, and groomed, and harnessed, he may not +find any great satisfaction in a toy horse, or pay much attention to +it, no matter how costly or realistic it may be.</p> + +<p>In the third year more precise tasks, such as stringing beads, +drawing, and painting, will play their part, while at the same time +the increased imaginative powers will give attraction to toy soldiers +or a toy tea-service. Playing at shop, robbers, and rafts are +developments of still later growth. In the child's games we recognise +the instinct of imitation—playing with dolls, sweeping and dusting, +playing at shop or visitors; the instinct of constructiveness—making +mud pies and sand castles, drawing or whittling a stick; and the +instinct of experiment—letting objects fall, rattling, hammering, +taking to pieces. All this activity must be encouraged, never unduly +repressed or destroyed. +<span class="pagenum">Page 99<a name="Page_99" id="Page_99"></a></span> +But whatever form it takes, the bulk of the +play must be carried on without the intervention of grown-up persons, +or it will lose its educative value and prove too exacting. If +grown-up people attempt to take part, the child will lose interest in +the play and turn his attention to them.</p> + +<p>Children differ very much in their attitude towards books. One child +quite early in the second year will be happy poring over picture +books, while another will seldom glance at the contents and finds +pleasure only in turning over the pages, opening and shutting them, +and carrying them from place to place. Such differences are natural +enough and foreshadow perhaps the permanent characteristics that +divide men and women, and produce in later life men of thought and men +of action, women who are Marthas and women who are Marys. +Nevertheless, we should bear in mind that there is danger in a +training that is too one sided, and that books and toys have both +their part to play in developing the powers of the child. All the +activities of the child should be used in as varied a way as possible. +The eye is but one doorway to knowledge and understanding, the ear is +another, the hand a third.</p> + +<p>From pictures an imaginative child will derive very strong +impressions, and mothers should be careful in their choice. It is +foolish to confuse the growth of æsthetic perceptions by presenting +children with books which depict children as grotesquely ugly beings +with goggle eyes and heads like rubber balls. Children love animals and +<span class="pagenum">Page 100<a name="Page_100" id="Page_100"></a></span> +endow them with all their own reasoning attributes, and in +stories of the home life of rabbits, and bears, and squirrels they +take a pure delight. Books of the "Struwwelpeter" type are less to be +recommended. The faults which they are intended to eradicate become +peculiarly attractive from much familiarity. A little boy of two and a +half who resolutely refused all food for some days was in the end +detected to be playing the part of that Augustus, once so chubby and +fat, who reduced himself to a skeleton, saying, "Take the nasty soup +away; I don't want any soup to-day." Tales of naughty children who +meet with a distressing fate may either frighten the child unduly, or +else produce in a child of inquiring mind the desire to brave his fate +and put the matter to the test. Pictures should not be terrifying or +horrible. Ogres devouring children are out of place as subjects for +pictures and may cause night-terrors.</p> + +<p>Children should be taught to be careful of books and toys. The +indestructible book, generally falsely so called, is often responsible +for the immediate dissolution of all others less protected which come +to hand. The sympathy which little children have with the sufferings +of all inanimate objects and their habit of endowing them with their +own sensations may be made of use in teaching them care and +gentleness. They are naturally prone to sympathise with the doll that +has been crushed or the book that has been torn. They will learn very +easily to be kind to a pet animal and to be solicitous for its +feelings, and the lesson so learnt will be applied to inanimate +objects as well.</p> + +<p><span class="pagenum">Page 101<a name="Page_101" id="Page_101"></a></span> +There is, however, another side to the question. It is true that if +the child is not to be over-stimulated upon the psychical side, we +must see to it that his play, for the most part, is not dependent upon +the participation of grown-up persons. In practice this excessive +stimulation is the common fault with which we meet. There are few +children in well-to-do homes, with loving mothers and devoted nurses, +who suffer from too little mothering and nursing. Too many show signs +of too much. To observe the opposite fault we must seek the infants +and children who for a long time are inmates of institutions, +orphanages, infirmaries, hospitals, and so forth. In such surroundings +the mental life of the child may languish. His physical wants are +cared for, but there the matter ends. In a rigid routine he is washed +and fed, but he may not be talked to or played with or stimulated in +any way. His day is spent passively lying in his cot, unnoticed and +unnoticing. I have seen a poor child of three years just released from +such a life, and after eighteen months returned to his mother, unable +to talk and almost unable to walk, crying pitifully at the novelty and +strangeness of the noisy life to which he had returned, worried by +contact with the other children, and without any desire or power to +occupy himself in the home. For an hour in the day mothers may devote +themselves wholeheartedly to the children, and if they set them +romping till they are tired out, so much the better. In the garden or +in an airy room with the windows open, a game with a ball or a toy +balloon, or a <span class="pagenum">Page 102<a name="Page_102" id="Page_102"></a></span> +game of hide-and-seek, will be all to the good, and the +children may climb and be rolled over and swung about to their heart's +content. With an only child, especially with a child whose home is in +town, and whose outings are limited to a sedate airing in the park, +such free play is especially necessary. It may help more than anything +else to quiet restless minds and tempers that are on edge all day long +from excessive repression.</p> + +<p>On the other hand, those forms of entertainment which are known as +"children's parties" are generally fruitful of ill results, at any +rate with nervous and highly-strung children. Sometimes they entail a +postponement of the usual bedtime, and nearly always they involve +over-heated and crowded rooms. Perverse custom has decreed that these +gatherings shall take place most commonly in the winter, when dark and +cold add nothing to the pleasure and a great deal to the risk of +infection which must always attend the crowding of susceptible +children together in a confined space with faulty ventilation. There +is clearly on the score of health much less objection to summer garden +parties for children, but these for some reason are less the vogue. As +a rule parties are not enjoyed by nervous children. There is intense +excitement in anticipation, and when at length the moment arrives, +there is apt to be disillusion. Either the excitement of the child may +pass all bounds and end in tears and so-called naughtiness, or the +unfamiliar surroundings may leave him distrait with a strange sense of +unreality and unhappiness. It is not +<span class="pagenum">Page 103<a name="Page_103" id="Page_103"></a></span> +always fair to blame the want of +wisdom in his hostess's choice of eatables, if the excited and +overstimulated child fails in the work of digestion and returns to the +nursery to suffer the reaction, with pains and much sickness.</p> + +<p>The same arguments may be urged against taking little children to the +theatre. The nerve strain is apt to be out of proportion to the +enjoyment gained. If children must go to theatres and parties, the +treat should be kept secret from them until the moment of its +realisation, in order that the period of mental excitement should be +contracted as much as possible, and grown-up people should be advised +to treat the whole expedition in a matter-of-fact sort of way that +does nothing to add to the excitement or increase the risk of +subsequent disillusion.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 104<a name="Page_104" id="Page_104"></a></span></p> +<h3>CHAPTER VIII</h3> + +<h3>NERVOUSNESS IN EARLY INFANCY</h3> +<p> </p> + +<p>We may now pass back to consider the nervous system of the child in +infancy. There, too, from the moment of birth there are clearly-marked +differences between individuals. The newborn baby has a personality of +his own, and mothers will note with astonishment and delight how +strongly marked variations in conduct and behaviour may be from the +first. One baby is pleased and contented, another is fidgety, +restless, and enterprising. At birth the baby wakes from his long +sleep to find his environment completely changed. Within the uterus he +lies in unconsciousness because no ordinary stimulus from the outer +world can reach him to exert its effect. He lies immersed in fluid, +which, obeying the laws of physics, exercises a pressure which is +uniformly distributed over all points of his body. No sound reaches +him, and no light. After birth all this is suddenly changed. The sense +of new points of pressure breaks in upon his consciousness. Cold air +strikes upon his skin. Loud sounds and bright lights evoke a +characteristic response. A placid child who inherits a relatively +obtuse nervous organisation will be but little upset by this sudden +<span class="pagenum">Page 105<a name="Page_105" id="Page_105"></a></span> +and radical change in the nature of his environment. His brain is +readily but healthily tired by the new sensations which stream in from +all sides, and he falls straight away into a sleep from which he +rouses himself at intervals only under the impulse of the new +sensation of hunger.</p> + +<p>Babies of nervous inheritance, on the other hand, will show clearly by +the violence of the response provoked that their nervous system is +easily stimulated and exhausted. They will wriggle and squirm for +hours together, emitting the same constant reflex cry. The whole body +will start convulsively at a sudden touch or a loud sound which would +evoke no response from a more stolid infant. The sleeplessness and +crying exhaust the baby, rendering the nervous system more and more +irritable, while the sensation of hunger which is delayed in other +children by twelve hours or more of deep sleep appears early and is of +extreme intensity. We must see to it that sense stimuli are reduced to +the lowest possible level. True, we cannot again restore the child to +a bath of warm fluid, of the same temperature as his body, where he +can be free from irksome pressure and from all sensations of sound and +light, but we can so arrange matters that he is not disturbed by loud +sounds and bright lights, and that he is not moved more than is +necessary. Sudden unexpected movements are especially harmful. Jogging +him up and down, patting him on the back, expostulation, and +entreaties are all out of place and do all the harm in the world. The +first bath should be as expeditious +<span class="pagenum">Page 106<a name="Page_106" id="Page_106"></a></span> +as possible, and above all the +baby must not be chilled by tedious exposure. Cold irritates his +nervous system more than anything else, unless it be excessive warmth. +In preserving the proper temperature so that we do not render the +child restless by excess of heat or by excess of cold, we +too-civilised people have made our own difficulties. We have +exaggerated the completeness of the sudden separation of mother and +child which nature decrees. It is the function of all mother animals +to approximate the unstable temperature of the newly born to their own +by the close contact of their bodies, which provide just the proper +heat. Labour is nowadays so complicated and exhausting a process for +mothers that, all things considered, we are wise in completing the +separation of mother and child and in removing the baby to his own +cot. But the difficulty remains, and we must arrange that any +artificial heating needed is constant and of proper degree.</p> + +<p>If the baby is very restless and irritable, too wide awake and too +conscious of his surroundings, the all-important task of getting him +to the breast and getting him to draw the milk into the breast is apt +to be difficult. His sucking is a purely reflex and involuntary act. +It can be produced by anything which gently presses down the tongue, +and a finger placed in the proper position will provoke the movement +without the child's consciousness being aroused. The placid child +whose mind is at rest will suck well and strongly. If, on the other +hand, the brain is too much stimulated and the child is restless and +<span class="pagenum">Page 107<a name="Page_107" id="Page_107"></a></span> +irritable, the reflex act of suction is inhibited, and it is a +difficult matter to get the child to the breast. He is too eager, +mouthing, and gulping, and spluttering. Or sometimes his mental +sufferings seem too much for his appetite, and though wide awake and +crying loudly, he refuses to grasp the nipple, turning his head away +and wriggling blindly hither and thither. This effect of mental unrest +on the newborn infant is often disastrous, because it is one of the +common causes of the failure of women to nurse their children. This is +not the place to sketch in detail a scheme for the proper technique of +breast nursing, a matter which is much misunderstood at the present +day. It will be enough shortly to say that an efficient supply of milk +depends upon the complete and regular emptying of the breast. The +breasts of all mothers will secrete milk if strong and vigorous +suction is applied to the nipple by the child. If anything interferes +with suction, the milk does not appear or, if it has appeared, it +rapidly declines in amount. The mother's part is to a great extent a +passive one, provided that she can supply one essential—a nipple that +is large enough for the child to grasp properly. Within wide limits +what the mother eats or drinks, whether she be robust or whether she +has always been something of an invalid, matters not at all. A frail +woman may naturally not be able to stand the strain of nursing for +many months, but that is not here the point in question. We are +dealing only with the establishment of lactation and with the milk +supply of the early days and weeks which is +<span class="pagenum">Page 108<a name="Page_108" id="Page_108"></a></span> +of such vital importance +for the child. If the mother is ill, if, for example, she has +consumption, we may separate her from the child in the interests of +both; but if this is not done, she will continue to secrete milk for a +time as readily as if she were in perfect health, and the breasts of +many a dying woman are to be seen full of milk. Mothers are too apt to +attribute the disappointment of a complete failure to nurse to some +weakness or want of robustness in their own health. This is never the +reason of the failure, and the fault, if the mother has a well-formed +nipple, is generally to be found in some disturbance in the child. +Prematurity, with extreme somnolence, breathlessness from respiratory +disease, nasal catarrh, which hinders breathing through the nose, +infections of all sorts, are common causes of this failure to suck +effectively. But perhaps the most common cause of all is the +inhibition from nervous unrest of that reflex act of sucking which +works so well in the placid and quiet child. It is a point to which +too little attention is paid, and mothers and the books which mothers +read commonly neglect the nervous system of the child and devote +themselves to such considerations as the relative merits of two-hourly +and four-hourly feedings—important points in their way, but less +important than this.</p> + +<p>The matter is complicated in two other ways. In the first place, the +nervous baby, just because he is so active and wakeful and restless, +is apt rapidly to lose weight and to have an increased need for food. +The restlessness is generally attributed to +<span class="pagenum">Page 109<a name="Page_109" id="Page_109"></a></span> +hunger, and this is true, +because hunger is soon added to the other sensations from which he +suffers, and like them is unduly acute. It is difficult not to give +way and to provide artificial food from the bottle. Yet if we do so we +must face the fact that these restless little mortals are quicker to +form habits than most, and once they have tasted a bottle that flows +easily without hard suction, they will often obstinately refuse the +ungrateful task of sucking at a breast which has not yet begun to +secrete readily. The suction that is devoted to the bottle is removed +from the breast, and the natural delay in the coming in of the milk is +increased indefinitely. At the worst, the supply of milk fails almost +at its first appearance. We must devote our attention to quieting the +nervous unrest by removing all unnecessary sensory stimulation from +the baby. He must be in a warm cot, in a warm, well-aired, darkened, +and silent room, and the necessary handling must be reduced to a +minimum. Sometimes sound sleep will come for the first time if he is +placed gently in his mother's bed, close to her warm body. If he is +apt to bungle at the breast from eagerness and restlessness, it is not +wise always to choose the moment when he has roused himself into a +passion of crying to attempt the difficult task. So far as is possible +he should be carried to the breast when he is drowsy and sleepy, not +when he is crying furiously, and then the reflex sucking act may +proceed undisturbed.</p> + +<p>In the second place, we must guard against the ill effect which the +ceaseless crying of these nervous +<span class="pagenum">Page 110<a name="Page_110" id="Page_110"></a></span> +babies has upon the mother. She may +be so exhausted by the labour that her nerves are all on edge, and she +grows apprehensive and frightened over all manner of little things. +The tired mother is apt to fear that she will have no milk, and her +agitation grows with each failure on the part of the child. Now the +first secretion of milk is very closely dependent upon the nervous +system of the mother. We have said that within wide limits her +physical condition is of less importance, but her peace of mind is +essential. And so it is wise for some part of the day to keep the +nervous baby out of hearing of the mother, and so far as possible to +choose moments when the child is quiet to put him to the breast. A +nurse with a confident, hopeful manner will effect most; a fussy, +over-anxious, or despondent attitude will do untold harm. We shall +sometimes fail if the nervous unrest is very obstinate either in +mother or in child, but we shall fail less often if we diagnose the +cause correctly in the cases we are considering. Lastly, it is +possible to control the condition in both mother and child by the +careful use of bromide or chloral.</p> + +<p>It is not, of course, suggested that these drugs should be given +freely or as a routine to every hungry baby wailing for the breast, or +that we can hope to combat or ward off an inherited neuropathy by a +few doses of a sedative. There are, however, not a few babies in whom +there develops soon after birth a sort of vicious circle. They can +suck efficiently and digest without pain only when they sleep soundly. +If they are put to the +<span class="pagenum">Page 111<a name="Page_111" id="Page_111"></a></span> +breast after much crying and restlessness, +each meal is followed by flatulence, colic, and renewed crying. The +only effective treatment is to secure sleep and to carry a slumbering +or drowsy infant to the breast. Then the sucking reflex comes to its +own again, the breast is drained steadily and well, and digestion +proceeds thereafter without disturbance and during a further spell of +sleep. Two or three times in the day we may be forced, as meal-time +approaches, to cut short the restlessness of the child by giving a +teaspoonful of the following mixture:</p> + +<table cellspacing="2" cellpadding="4" border="0" summary="Mixture for restless child"> +<tr> + <td>Pot. brom., </td> + <td>grs. ii. [2 grains]</td> +</tr> +<tr> + <td>Chloral hydrate,</td> + <td>gr. i. [1 grain]</td> +</tr> +<tr> + <td>Syrup,</td> + <td><img src="images/minim.gif" width="30" height="29" alt="Symbol: minim" title="Symbol: minim" /> x. [10 minims]</td> +</tr> +<tr> + <td>Aq. menth. pip., ad </td> + <td><img src="images/dram.gif" width="16" height="24" alt="Symbol: dram" title="Symbol: dram" /> i. [1 dram]</td> +</tr> +</table> + +<p>After this has been taken the child should be laid down for a quarter +of an hour until soundly asleep. Then very gently he can be carried to +his mother and the nipple inserted. If in this way a few days of sound +sleep and less disturbed digestion can be secured, the difficulty will +in most cases permanently be overcome. The steadier suction and more +efficient emptying of the breast will promote a freer flow of milk, +and the deeper and more prolonged sleep will lower greatly the needs +of the child for food. Most of the babies who show this fault are +thin, meagre, and fidgety, and with some increase of muscular tone. +The head is held up well, the limbs are stiff, the hands clenched, the +abdomen retracted, with the outline of the recti muscles unusually +prominent. If we can +<span class="pagenum">Page 112<a name="Page_112" id="Page_112"></a></span> +relax this exaggerated state of nervous tension, +if we can help them to become fatter and to put on weight, the +dyspepsia will disappear with the other symptoms.</p> + +<p>It is a question still to be answered whether the rare conditions of +pyloric spasm and pyloric hypertrophic stenosis are not further +developments of the same disturbance. Certainly these grave +complications appear most commonly in infants with a pronounced +nervous inheritance, and, as might be expected, they are more commonly +found in private practice than among the hospital classes.</p> + +<p>In passing, we may note that there are babies who exhibit the opposite +fault, and in whom the contrary regimen must be instituted. Premature +children, children born in a very poor state of nutrition, and +children born with great difficulty, so that they are exhausted by the +violence of their passage into the world, are apt to show the opposite +fault of extreme somnolence. They are so little stimulated by their +surroundings, and they sleep so profoundly, that the sucking reflex is +not aroused. Put to the breast they continue to slumber, or after a +few half-hearted sucking movements relapse into sleep. We must rouse +such children by moving them about and stirring them to wakefulness +before we put them to the breast.</p> + +<p>Once the child has been got to the breast, once the milk has become +firmly established, we have overcome the first great difficulty which +besets us in the management of nervous little babies, but it is by no +means the last. Restlessness and continual +<span class="pagenum">Page 113<a name="Page_113" id="Page_113"></a></span> +crying must be combated or +digestion suffers, and may show itself in a peculiar form of explosive +vomiting, which betokens the reflex excitability and unrest of the +stomach.</p> + +<p>The sense of taste is as acute as all other sensations. If the child +is bottle-fed, the slightest change in diet is resented because of the +unfamiliar taste, and the whole may promptly be rejected. The tendency +to dyspeptic symptoms is apt to lead to much unwise changing of the +diet, and everything tried falls in turn into disrepute, until perhaps +all rational diets are abandoned, and some mixture of very faulty +construction, because of its temporary or accidental success, becomes +permanently adopted—a mixture perhaps so deficient in some necessary +constituent that, if it is persisted with, permanent damage to the +growth of the child results. We must pay less attention to changes of +diet and explore our management of the child to try and find how we +can make his environment more restful.</p> + +<p>It is wise to accustom a nervous child from a very early age to take a +little water or fruit juice from a spoon every day. Otherwise when +breast-feeding or bottle-feeding is abandoned one may meet with the +most formidable resistance. Infants of a few months can be easily +taught; the resistance of a child of nine months or a year may be +difficult to overcome. The difficulty of weaning from the breast +recurs with great constancy in nervous children. By this time the +influence of environment has become clearly apparent. The child is +often enough already master of the situation, +<span class="pagenum">Page 114<a name="Page_114" id="Page_114"></a></span> +and is conscious of his +power. Such children will sometimes prefer to starve for days +together, obstinately opposing all attempts to get them to drink from +a spoon, a cup, or even a bottle. When this happens, sometimes the +only effective way is to change the environment and to send the baby +to a grandmother or an aunt, where in new surroundings and with new +attendants the resistance which was so strong at home may completely +disappear. When weaning is resented, and difficulties of this sort +arise, it is clear that the mother, whose breast is close at hand, is +at a great disadvantage in combating the child's opposition.</p> + +<p>For nervous infants, alas! broken sleep is the rule. What, then, is to +be done? It is astonishing to me that any one who has studied the +behaviour of only a few of these nervous and restless infants should +uphold the teaching that the crying of the young infant is a bad +habit, and that the mother who is truly wise must neglect the cry and +leave him to learn the uselessness of his appeals. It is true that the +youngest child readily contracts habits good or bad. Either he will +learn the habit of sleep or the habit of crying. Mercifully the +inclination of the majority is towards sleep. But to encourage habits +of restlessness and crying there is no surer way than to follow this +bad advice and to permit the child to cry till he is utterly exhausted +in body and in mind. It is unwise <i>always</i> to rock a baby to sleep; it +is also unwise to allow him to scream himself into a state of +hysteria. A quiet, darkened room, the steady pressure of the mother's hand in +<span class="pagenum">Page 115<a name="Page_115" id="Page_115"></a></span> +some rhythmical movement, will often quiet an incipient +storm. The longer he cries, the more trouble it is to soothe him. +Sleep provokes sleep, so that often we find restlessness and sound +sleep alternating in a sort of cycle, a good week perhaps following a +bad one. The nurse who is quick to cut short a storm of crying and to +soothe the child again to sleep is helping him to form habits of +sleep. The nurse who leaves him to cry, believing that in time he will +of his own accord recognise the futility of his behaviour, is making +him form habits of crying. A rigid routine in sleep is a good thing, +but the routine belongs to the baby, not to the nurse. The child must +be educated to sleep, not taught to cry. A baby has but little power +of altering his position when it becomes strained or uncomfortable. He +cannot turn over and nestle down into a new posture. If we watch him +wake, the first stirring may be very gradual, and in a moment he may +fall again to sleep. A few minutes later he stirs again more strongly, +and is wider awake and for longer. It may only be after a third +waking, by a summation of stimuli, that he is finally roused and +breaks into loud crying. The nurse who is on the watch, who, sleeping +beside him, wakes at the slightest sound and is quick to turn him over +and settle him into a new position of rest, will probably report in +the morning that the baby has had a good night. The nurse who lets the +child grow wide awake and start crying loudly, will spend perhaps many +hours before quiet is again restored. Of the voluntary, purposive +crying of infants a little older +<span class="pagenum">Page 116<a name="Page_116" id="Page_116"></a></span> +I am not here speaking. Infants in +the second six months are quite capable of establishing a "Tyranny of +Tears" and feeling their power. Fortunately it requires no great +experience to distinguish one from the other, and to adopt for each +the appropriate treatment.</p> + +<p>Again, in elementary teaching upon the management of infants stress is +laid, rightly enough, upon the importance of regularity in the times +of feeding, and on the observance in this respect also of a very +strict routine. But in the case of the very nervous infant a certain +latitude should be allowed to an experienced nurse or mother. We may +wreck everything by a blind adhesion to a too rigid scheme, which may +demand that we leave the child to scream for an hour before his meal, +or that, when at length he has fallen into a sound sleep after hours +of wakefulness, we should proceed to wake him.</p> + +<p>Symptoms of dyspepsia which are due to continued nervous excitement +demand treatment which is very different from that which would be +appropriate to dyspepsia which is due to other causes, such as +overfeeding or unsuitable feeding. The temporary restriction of food, +which is commonly ordered in dyspepsia from these causes, is very +badly supported by the nervous infant. Hunger invariably increases the +unrest, and the unrest increases the dyspepsia.</p> + +<p>The difficulties of managing a nervous infant are very real, and call +for the most exemplary patience on the part of the mother and the +clearest insight into the nature of the disturbance.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 117<a name="Page_117" id="Page_117"></a></span></p> + +<h3>CHAPTER IX</h3> + +<h3>MANAGEMENT IN LATER CHILDHOOD</h3> + + +<p>In the early days in the nursery the actions of the infant, for the +most part, follow passively the traction exercised by nurses and +mothers, sometimes consciously, but more often unconsciously. We have +now to consider a period when the child becomes possessed of a driving +force of his own, and moves in this direction or that of his own +volition. In this new intellectual movement through life he will not +avoid tumbles. He will feel the restraints of his environment pressing +upon him on all sides, and he will often come violently in contact +with rigid rules and conventions to which he must learn to yield. From +time to time we read in the papers of some terrible accident in a +picture-palace, or in a theatre. Although there has been no fire, +there has been a cry of fire, and in the panic which ensues lives are +lost from the crowding and crushing. Yet all the time the doors have +stood wide open, and through them an orderly exit might have been +conducted had reason not given place to unreason. It is the task of +those responsible for the children's education to guide them without +wild struggling along the paths of +<span class="pagenum">Page 118<a name="Page_118" id="Page_118"></a></span> +well-regulated conduct towards the +desired goal, influenced not by the emotions of the moment, but only +by reason and a sense of right; not ignorant of the difficulties to be +met, but practised and equipped to overcome them.</p> + +<p>It is easy thus to state in general terms the objects of education, +and the need for discipline. To apply these principles to the +individual is a task, the immeasurable difficulty of which we are only +beginning to appreciate with the failure of thirty years of compulsory +education before us. A recent writer<a name="FNanchor_2_2" id="FNanchor_2_2" /> +<a href="#Footnote_2_2" class="fnanchor">[2]</a> gives it as his opinion that +the aim of education is to equip a child with ideals, and that this +task should not be difficult, because the lower savages successfully +subject all the members of their tribe to the most ruthless +discipline. Their lives, he says, "are lived in fear, in restraint, in +submission, in suffering, subject to galling, unreasoning, +unnecessary, arbitrary prohibitions and taboos, and to customary +duties equally galling, unreasoning, unnecessary, and arbitrary. They +endure painful mutilations, they submit to painful sacrifices.... How +are these wild, unstable, wayward, impulsive, passionate natures +brought to submit to such a rigorous and cruel discipline? By +education; by the inculcation from infancy of these ideals. In these +ideals they have been brought up, and to them they cling with the +utmost tenacity." One might as well contend that it was easy to teach +all men to live the self-denying life of earnest Christians because +some savage tribe was successful in main +<span class="pagenum">Page 119<a name="Page_119" id="Page_119"></a></span> +taining among its members a +universal and orthodox worship of idols. The ideals set before the +child are too high and too complex to be inculcated by physical force, +or even by force of public opinion. A rigid discipline, with many +stripes and with terrible threats of a still worse punishment in the +world to come, was the almost invariable lot of children until the +last century was well advanced. Yet has this drastic treatment of +young children fulfilled its purpose? Were the men of fifty years ago +better conducted and more controlled than the men of to-day? In any +one family did a greater proportion turn out well? Is it not true that +at least among the educated classes the relaxation of nursery and +schoolroom discipline which the last fifty years has seen has been +justified by its results? Is it not true that the childhood of our +grandmothers was often lived "in fear, in restraint, in submission, in +suffering subject to galling, unreasoning, unnecessary, arbitrary +prohibitions and taboos, and to customary duties equally galling, +unreasoning, unnecessary, and arbitrary." And though perhaps the +grandmothers of most of us may not have been much the worse for all +this discipline, is it not true that of the little brothers who shared +the nursery with them a surprising number broke straightway into +dissipation when the parental restraints were removed? If we are to +teach a child to be gentle to the weak it is not wise to beat him. The +qualities which we wish him to possess are not more subtle than the +means by which we must aid him to their possession.</p> + +<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2" /><a href="#FNanchor_2_2"> +<span class="label">[2]</span></a> <i>The Principles of Rational Education</i>, by Dr. C.A. +Mercier.</p></div> + +<p>Education comprises physical, mental, and moral +<span class="pagenum">Page 120<a name="Page_120" id="Page_120"></a></span> +training. In earlier +times physical strength and the power to fight well, alone were prized +and were the chief objects to be gained in the education of youth. +Later, under the stress of intellectual competition for success in +life, mental acquirements have come to occupy the first place. We are +only now learning to lay emphasis upon the supreme need for moral +training. Not that it is possible to separate the sum of education +into its constituent parts, and to regard each as distinct from the +others. That many men of great intellectual activity, and many men +pre-eminent for their moral qualities have harboured a great brain or +a noble character in a weakly or deformed body, forms no argument to +disprove the general rule that a healthy, vigorous physique is the +only sure foundation upon which to build a highly developed intellect +and a stable temperament. In childhood the intimate connection between +vigour of mind and vigour of body is almost always clearly shown. A +child with rickets, unable to exercise his body in free play, as a +rule shows a flabbiness of mind in keeping with his useless muscles +and yielding bones. Such children talk late, are infantile in their +habits and ways of thought, and are more emotional and unstable than +healthy children of the same age. The connection between bodily +ailments and instability of nervous control is even more clearly seen +in the frequent combination of rheumatism and chorea. A very high +proportion of older children suffering from the graver neuroses, such +as chorea, syncopal attacks, phobias, tics, and so forth, show defective physical +<span class="pagenum">Page 121<a name="Page_121" id="Page_121"></a></span> +development. Scoliosis, lordosis, knock-knee, flat +foot, pigeon chest, albuminuria, cold and cyanosed extremities, are +the rule rather than the exception. If the body of the child is +developed to the greatest perfection of which it is capable we shall +not often find a too sensitive nervous system. The boy of fine +physique may have many faults. He may be bad-tempered or untruthful or +selfish, but such faults as he has are as a rule more primitive in +type, more readily traced to their causes, and more easy to eradicate +than the faults which spring from that timidity, instability, and +moral flabbiness which has so often developed in the lax delicate +child reared softly in mind and body.</p> + + +<p class="subhead">Physical Training</p> + +<p>Children thrive best in the healthy open-air life of the country, and +if there is any tendency to nervous disturbances the need for this +becomes insistent. Physical training, further, includes the manual +education of the child. The system of child-training advocated by Dr. +Montessori is based upon the cultivation of tactile sensations and the +development of manual dexterity. Exercises such as she has devised +have an immediate effect in calming the nervous system and in changing +the restless or irritable child into a self-restrained and eager +worker. Lord Macaulay, whose phenomenal memory as a child has become +proverbial, was so extraordinarily unhandy that throughout life he had +considerable difficulty in putting on his gloves, +<span class="pagenum">Page 122<a name="Page_122" id="Page_122"></a></span> +while he had such +trouble with shaving that on his return from India there were found in +his luggage some fifty razors, none of which retained any edge, and +nearly as many strops which had been cut to pieces in his irritated +and ineffectual efforts. If we teach a child manual dexterity it is an +advantage to him, because manual dexterity is seldom associated with +restlessness and irritability of mind. To excel in some handicraft not +only bespeaks the possession of self-control, it helps directly to +cultivate it. The teaching of Froebel and Montessori holds good after +nursery days are over.</p> + + +<p class="subhead">Mental Training</p> + +<p>Mental training enables the child to retain facts in his memory, to +obtain information from as many sources as possible, to understand and +piece them together, and finally to reach fresh conclusions from +previously acquired data. So far as is possible the teacher must +satisfy the natural desire to know the reason of things. It must be +his endeavour to prevent the child from accepting any argument which +he has not fully understood, and which, as a result, he is able not to +reconstruct but only to repeat. Mental work which is slovenly and +perfunctory is as harmful to the child's education as mechanical work +which is bungled and ineffective. Taking advantage of his natural +aptitudes, his interest should be developed and extended in every way +possible. Tasks which are accomplished without enthusiasm are labour +expended in vain, +<span class="pagenum">Page 123<a name="Page_123" id="Page_123"></a></span> +because the knowledge so acquired is not +assimilated and adds nothing to the child's mental growth. There +should be no sharp differentiation between work and play.</p> + + +<p class="subhead">Moral Training</p> + +<p>Moral training depends upon the force of example rather than of +precept. Parents must be scrupulously just and truthful to the child, +for his quick perception will detect the slightest deceit, and the +evil impression made on his mind may be lasting. They must confidently +expect conduct from him of a high moral standard, and be careful at +this early age to avoid the common fault of giving a dog a bad name. +If it is said on all sides that a child has an uncontrollable temper, +is an inveterate grumbler, is lacking in all power of concentration, +or has a tendency to deceit, it is likely that the child will act up +to his reputation. He comes in time to regard this failing of his as +part of himself just as much as is the colour of his hair or the +length of his legs. It may be said of a schoolboy that he shows no +aptitude for his work. Term by term the same report is brought home +from school, and each serves only to confirm the boy in his belief +that this failing is part of his nature, and that no effort of his own +can correct it. If one subject only has escaped the condemnation of +his master, then it may be to that study alone that he returns with +zest and enjoyment. Spendthrift sons are manufactured by those fathers +who many times a day proclaim that the boy has no notion of the value +of money.</p> + +<p><span class="pagenum">Page 124<a name="Page_124" id="Page_124"></a></span> +And so with children! Parents must take it for granted that they will +display all the virtues they desire in them. They must trust to their +honour always to speak the truth, and always to do their best in work +or play whether they are with them or not. Again and again the +children will fail and their patience will be tried to the utmost. +They must explain how serious is the fault, and for the time being +their trust may have to be removed; but with the promise of amendment +it must again be fully restored and the lapse completely forgotten. If +the child feels he is not trusted he ceases to make any effort, and +lapse will succeed lapse with increasing frequency.</p> + +<p>In efforts at moral training there is often too great an emphasis laid +upon negative virtues. It is wrong to do this: to do that is +forbidden. Children cannot progress by merely avoiding faults any more +than a man may claim to be an agreeable companion at table because he +does not eat peas with a knife or drink with his mouth full. There +must be a constant effort to achieve some positive good, to acquire +knowledge, to do service, to take thought for others, to discipline +self, and the parent will get the best result who is comparatively +blind to failure but quick to encourage effort and to appreciate +success. When the child knows well that he is doing wrong, exhortation +and expostulation are usually of little avail if repeated too often, +and serious talks should only take place at long intervals.</p> + +<p>We know how effective the so-called "therapeutic +<span class="pagenum">Page 125<a name="Page_125" id="Page_125"></a></span> +conversation" may be +in helping some overwrought and nervously exhausted man or woman to +regain peace of mind and self-control. After an intimate conversation +with a medical man who knows how to draw from the patient a free +expression of the doubts, anxieties, and fears which are obsessing +him, many a patient feels as though he had awakened in that instant +from a nightmare, and passes from the consulting-room to find his +troubles become of little account. Not a few patients return to be +reassured once more, and derive new strength on each occasion. Yet +visits such as these must be infrequent or they will lose their power. +Now, just as the physician is well aware that his intervention if too +frequently repeated will lose its effect, so the parent must be chary +of too frequent an appeal to the moral sense of the child. At long +intervals opportunity may be taken with all seriousness to set before +the child ideals of conduct, to-speak to him of the meaning of +character and of self-discipline, and of the standards by which we +judge a man or woman to be weak and despicable, or strong and to be +admired. The effect of such an intimate conversation, never repeated, +may persist throughout life. Constantly reiterated appeals, on the +other hand, do more harm than good. To tell a child daily that he is +"breaking mother's heart," or that he is "disappointing his father," +is to debase the moral appeal and deprive it of its strength.</p> + +<p>For everyday use it is best to cultivate a manner which can indicate +to the child that he is for the +<span class="pagenum">Page 126<a name="Page_126" id="Page_126"></a></span> +moment unpopular, but which at the +same time denies to the small sinner the interest of attempting his +own defence. On the other hand, should the child be reasonably in +doubt as to the nature of his offence we must spare no trouble in +explaining it to him. Punishment will be most effective when the child +is convinced that he is rightly convicted. If it is to act as a real +deterrent, he must agree to be punished—a frame of mind which, if it +can be produced, may be welcomed as a sure sign that training is +proceeding along the right lines.</p> + +<p>By physical training, mental training, and moral training the child's +character is formed and self-discipline is developed. With the child +of neuropathic disposition and inheritance matters may not proceed so +smoothly. Reasoning and conduct may be alike faulty, and the nervous +disturbances may even cause detriment to the physical health. Not that +the nervous child requires an environment different from that of the +normal child. The difficulties which the parents will encounter and +the problems which must be solved differ not in kind but in degree. An +error of environment which is without effect in the normal child may +be sufficient to produce disastrous results in the neuropathic.</p> + +<p>It must be granted that there are some unfortunate children in whom +the moral sense remains absent and cannot be developed—children who +steal and lie, who seem destitute of natural affection, or who appear +to delight in acts of cruelty. These moral degenerates need not be +considered here. Serious errors of conduct, however, in children who are not +<span class="pagenum">Page 127<a name="Page_127" id="Page_127"></a></span> +degenerate or imbecile, frequently arise directly from faults +of management and can be controlled by correcting these faults. +Suppose, for example, that a child is found to have taken money not +his own. The action of the parents faced with this difficulty and +disappointment will determine to a great extent whether the incident +is productive of permanent damage to the child's character. The +peculiar circumstances of each case must be considered. For example, +the parent must bear in mind the relation in which children stand to +all property. The child possesses nothing of his own; everything +belongs in reality to his father and mother, but of all things +necessary for him he has the free and unquestioned use. Unless his +attention has been specially directed to the conception of ownership +and the nature of theft, he may not have reasoned very closely on the +matter at all. Very probably he knows that it is wrong to take what is +not given him, but he does not regard helping himself to some dainty +from a cupboard as more than an act of disobedience to authority. He +may have imbibed no ideas which place the abstraction of money from a +purse belonging to his parents on a different plane, and which have +taught him to regard such an action as especially dishonourable and +criminal. Finally, a child who, undetected, has more than once taken +money belonging to his father and mother, may pass without much +thought to steal from a visitor or a servant. To deal with such a case +effectively, to ensure that it shall never happen again, requires much +insight. If the father, +<span class="pagenum">Page 128<a name="Page_128" id="Page_128"></a></span> +shocked beyond measure to find his son an +incipient criminal, differing in his guilt in no way from boys who are +sent to reformatories as bad characters, convinces the child that +although he did not realise it, he has shown himself unworthy of any +further trust, untold harm will be done. Almost certainly the child +will act in the future according to the suggestions which are thus +implanted in his mind. If the household eyes him askance as a thief, +if confidence is withdrawn from him, he sees himself as others see him +and will react to the suggestions by repeating the offence. The +seriousness of what he has done should be explained to him, and after +due punishment he must be restored completely and ostentatiously to +absolute trust. Only by showing confidence in him can we hope to do +away with the dangers of the whole incident. To inculcate good habits +and encourage good behaviour we must let the child build up his own +reputation for these virtues. It need not make him priggish or +self-satisfied if parents let him understand that they take pride in +seeing him practise and develop the virtue they aim at. For example, +it is desired above all that he should always speak the truth. Then +they must ostentatiously attach to him the reputation of truthfulness +and show their pride in his possessing it. If he falls from grace they +must remember that he is still a child, and that if that reputation is +lightly taken from him and he is accused of a permanent tendency +towards untruthfulness, he is left hopeless and resigned to evil. Let +any mother make the experiment of presenting +<span class="pagenum">Page 129<a name="Page_129" id="Page_129"></a></span> +to her child in this way +a reputation for some particular virtue. For example, if an older +child shows too great a tendency to tease and interfere with the +younger children, let the mother seize the first opportunity which +presents itself to applaud some action in which he has shown +consideration for the others. Let her comment more than once in the +next few days on how careful and gentle the older child is becoming in +his behaviour to the little ones, and in a little the suggestion will +begin to act until the transformation is complete. If, on the other +hand, the mother adopts the opposite course and rebukes the child for +habitual unkindness, she will be apt to find unkindness persisted in. +The criminal records of the nation show too often the truth of the +saying that "Once a thief always a thief." Deprived of his good +repute, man loses his chief protection against evil and his incentive +to good.</p> + +<p>The inability of a child—and especially of a nervous and sensitive +child—to form conceptions of his own individuality except from ideas +derived from the suggestions of others, gives us the key to our +management of him and to our control of his conduct. He has, as a +rule, a marvellously quick perception of our own estimate of him, and +unconsciously is influenced by it in his conception of his own +personality, and in all his actions. Parents must believe in his +inherent virtue in spite of all lapses. If they despair it cannot be +hid from the child. He knows it intuitively and despairs also. It is +then that they call him incorrigible. If it +<span class="pagenum">Page 130<a name="Page_130" id="Page_130"></a></span> +happens that one parent +becomes estranged from the child, despairs of all improvement, and +sees in all his conduct the natural result of an inborn disposition to +evil, while the other parent holds to the opinion that the child's +nature is good, and to the belief that all will come right, then often +enough the child's conduct shows the effect of these opposite +influences. In contact with the first he steadily deteriorates, +affording proof after proof that judgment against him has been rightly +pronounced. In contact with the other, though his character and +conduct are bound to suffer from such an unhappy experience, he yet +shows the best side of his nature and keeps alive the conviction that +he is not all bad.</p> + +<p>The force of suggestion is still powerful to control conduct and +determine character in later childhood. The impetus given by the +parents in this way is only gradually replaced by the driving power of +his own self-respect—a self-respect based upon self-analysis in the +light of the greater experience he has acquired.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 131<a name="Page_131" id="Page_131"></a></span></p> + +<h3>CHAPTER X</h3> + +<h3>NERVOUSNESS IN OLDER CHILDREN</h3> +<p> </p> + +<p>In older children the line which separates naughtiness, fractiousness, +and restlessness from definite neuropathy begins to be more marked. +The nature of the young child, taking its colour from its +surroundings, is sensitive, mobile, and inconstant. With every year +that passes, the normal child loses something of this impressionable +and fluid quality. With increasing experience and with a growing power +to argue from ascertained facts, character becomes formed, and if +tempered by discipline will come to present a more and more unyielding +surface to environment, until finally it becomes set into the +stability of adult age.</p> + +<p>We may perhaps, with some approach to truth, look upon the adult +neurotic as one whose character retains something of the +impressionable quality of childhood throughout life, so that, to the +last, environment influences conduct more than is natural.</p> + +<p>All the emotions of neurotic persons are exaggerated. Disappointments +over trifles cause serious upsets; grief becomes overmastering. +Violent and perhaps ill-conceived affection for +<span class="pagenum">Page 132<a name="Page_132" id="Page_132"></a></span> +individuals is apt to +be followed by bitter dislike and angry quarrelling. On the physical +side, sense perception is abnormally acute, and many sensations which +do not usually rise up into consciousness at all become a source of +almost intolerable suffering. To these most unhappy people summer is +too hot and winter too cold; fresh air is an uncomfortable draught, +while too close an atmosphere produces symptoms of impending +suffocation.</p> + +<p>In some neurotics there is an excessive interest in all the processes +of the life of the body, and when attention is once attracted to that +which usually proceeds unconsciously, symptoms of discomfort are apt +to arise. Thus so simple an act as swallowing may become difficult, or +for the time being impossible. To breathe properly and without a sense +of suffocation may seem to require the sustained attention of the +patient; or again, the voice may be suddenly lost.</p> + +<p>More commonly, perhaps, neuropathy exhibits itself in an undue +tendency to show signs of fatigue upon exertion of any sort, mental or +physical. Sustained interest in any pursuit or task becomes +impossible. Nameless fears and unaccountable sensations of dread +establish themselves suddenly and without warning, and may be +accompanied on the physical side by palpitation, flushing, headache, +or acute digestive disturbances.</p> + +<p>All these manifestations are best controlled by selecting a suitable +environment, and as a rule the character of the environment is +determined by the temperament and disposition of those who live +<span class="pagenum">Page 133<a name="Page_133" id="Page_133"></a></span> +in close contact with the patient. Like the tiny children with whom we +have dealt so far, the behaviour of neuropathic persons is subject +wholly to the direction of stronger and more dominant natures. With +faulty management at the hands of those around them, no matter how +loving and patient these may be, the conduct of the neurotic tends to +become abnormal.</p> + +<p>In children beyond earliest infancy we recognise a gradual approach to +the conditions of adult life. Fractiousness and naughtiness, +ungovernable fits of temper, inconsolable weeping and inexplicable +fears should disappear with early childhood even if management has not +been perfect. If they persist to older childhood we shall find in an +increasing percentage of cases evidence of definite neuropathic +tendencies which urgently call for investigation and for a precise +appreciation of the nature of the abnormality. It may be that the only +effective treatment is that which we recognise as essential in the +grosser mental disturbances—removal from the surroundings in which +the abnormal conduct has had free play, and separation from the +relatives whose anxiety and alarm cannot be hidden.</p> + +<p>In young nervous children fear is the most prominent psychical +symptom. The children are afraid of everything strange with which they +come in contact. They are afraid of animals, of a strange face, or an +unfamiliar room. Older children usually manage to control themselves, +suppress their tears, and prevent themselves from +<span class="pagenum">Page 134<a name="Page_134" id="Page_134"></a></span> +crying out, but it is nevertheless easy to detect the struggle.</p> + +<p>Often we find those distressing attacks to which the name +"night-terrors" has been given. The child wakes with a cry,—usually +soon after he has gone to sleep,—sits up in bed and shows signs of +extreme terror, gazing at some object of his dreams with wide-open +startled eyes, begging his nurse or mother to keep off the black dog, +or the man, or whatever the vision may be. Even after the light is +turned up and the child has been comforted, the terror continues, and +half an hour may elapse before he becomes quiet and can be persuaded +to go back to bed. In the morning as a rule he remembers nothing at +all.</p> + +<p>Phobias of all sorts are common in nervous children, and result from a +morbid exaggeration of the instinct for self-preservation. Some cannot +bear to look from a height, others grow confused and frightened in a +crowd; dread of travelling, of being in an enclosed space such as a +church or a schoolroom, or of handling sharp objects may develop into +a constant obsession. I have known a little girl who was seized with +violent fear whenever her father or mother was absent from the house, +and she would stand for hours at the window in an agony of terror lest +some harm should have befallen them. As if with some strange notion of +propitiating the powers of darkness these children will often +constantly perform some action and will refuse to be happy until they +have done so. The same little girl who suffered such torments of anxiety +<span class="pagenum">Page 135<a name="Page_135" id="Page_135"></a></span> +in her parents' absence would always refuse to go to bed +unless she had stood in turn on all the doormats on the staircase of +her home. Other children feel themselves forced to utter certain words +or to go through certain rhythmical movements. They fully understand +that the fear in their mind is irrational and devoid of foundation, +but they are unable to expel it. Often it is hugged as a jealous +secret, so that the childish suffering is only revealed to others +years afterwards, when adult age has brought freedom from it. We will +do well to try by skilful questioning to gain an insight into the +mental processes of a child when we find him showing an uncontrollable +desire to touch lamp-posts or to stand in certain positions; or when +he develops an excessive fear of getting dirty, or is constantly +washing his hands to purify them from some fancied contamination.</p> + +<p>The treatment of all these symptoms calls for much insight. The +child's confidence must be completely secured, and he must be +encouraged to tell of all his sensations and of the reasons which +prompt his actions. The nervous child has a horror of appearing unlike +other children, and will suffer in silence. If his troubles are +brought into the light of day with kindness and sympathy they will +melt before his eyes. Even night-terrors are, as a rule, determined by +the suppressed fears of his waking hours. If they are provoked by his +experiences at school, by the fear of punishment or by dismay at a +task that has proved beyond his powers, he should be taken away from school for +<span class="pagenum">Page 136<a name="Page_136" id="Page_136"></a></span> +the time being. Night-terrors are said to be aggravated by +nasal obstruction due to adenoid vegetations. Clothing at night should +be light and porous, and particular attention should be paid to the +need for free ventilation.</p> + +<p>We have spoken in an earlier chapter of the trouble sometimes +experienced in inducing a nervous child to go to sleep. In older +children insomnia is common enough. Even when sleep comes it may be +light and broken, as though the child slept just below the surface of +consciousness and did not descend into the depths of sound and +tranquil slumber. We have often noticed how different is the estimate +of the patient from that of the nurse as to the number of hours of +sleep during the night. The sick man maintains that he has hardly +slept at all, whilst the nurse, drawing us aside, whispers in our ear +that he has slept most of the night. In estimating sleep we have to +consider not only its duration, but also its depth, and the patient +who denies that he has slept at all has lain perhaps half the night +with an active restless brain betwixt sleep and wakefulness. Often +enough when he comes to consider in the morning the problems that +vexed his soul at midnight, he is quite unable to recall their nature, +and recognises them as the airy stuff that dreams are made of. +Although in a sense asleep he may have retained a half-consciousness +of his surroundings and a sense of despair at the continued absence of +a sounder sleep.</p> + +<p>With nervous children we are apt to find sleep +<span class="pagenum">Page 137<a name="Page_137" id="Page_137"></a></span> +which is of little depth and which constantly shows evidence of a too-active brain. The +body is tossed to and fro, words are muttered, and the respiration is +hurried and with a change in rhythm, because there is no depth of +anæsthesia. The body still responds to the impulses of the too-active +brain. From the nature of his dream—as shown by chance words +overheard—we may sometimes gather hints to help us to find where the +elements of unrest in his daily life lie. Sleep-walking is only a +further stage in this same disorder of sleep, in which the dream has +become so vivid that it is translated into motor action.</p> + +<p>If a child begins to suffer from active sleeplessness we must not make +the mistake of urging him to sleep. He is no more capable than we are +ourselves of achieving sleep by an effort of will power. To urge him +to sleep is likely to cause him to keep awake because we direct his +attention to the difficulty and make him fear that sleep will not +come. If he understands that all that he needs is rest, he will +probably fall asleep without further trouble.</p> + +<p>Day-dreams also may become abnormal, and tell of an unduly nervous +temperament. Any one who watches a little child at play will realise +the strength of his power of imagination. The story of Red Riding Hood +told by the nursery fire excites in the mind of the child an +unquestioning belief which is never granted in later life to the most +elaborate efforts of the theatre. All this imaginative force is +natural for the child. It becomes abnormal only when things seen and +acts performed in imagination +<span class="pagenum">Page 138<a name="Page_138" id="Page_138"></a></span> +are so vivid as to produce the +impression of actual occurrences, and when the child is so under the +sway of his day-dreams that he fails to realise the difference between +pretence and reality. Imagination which keeps in touch with reality by +means of books and dolls and toys is natural enough. Not so +imagination which leads to communion with unseen familiars or to acts +of violence due to the organisation of "conspiracies" or "robber +bands" amongst schoolboys.</p> + +<p>If evidence of abnormal imagination appears, the child must be kept in +close touch with reality. We must give him interesting and rational +occupation, such as drawing, painting, the making of collections of +all sorts, gardening, manual work, and so forth. In older children we +must especially supervise the reading.</p> + +<p>In many nervous children we find a faulty contact with environment, so +that instead of becoming interested in the thousand-and-one happenings +of everyday life and experiences, they become introspective and +self-conscious. As a result, sensations of all sorts, which are +commonly insufficient to arouse the conscious mind, attract attention +and, rising into consciousness, occupy the interest to the exclusion +of everything else. The conscious mind is not capable of being +occupied by more than one thing at a time. If attention is +concentrated upon external matters, bodily sensations, even extreme +pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells +us, hardly feels the scalping-knife as he shouts his death song. +<span class="pagenum">Page 139<a name="Page_139" id="Page_139"></a></span> +The soldier in the excitement of battle is often bereft of all sense of +pain. On the other hand, the patient who is morbidly self-conscious +becomes oblivious of his surroundings while he suffers intensely from +sensations which are usually not appreciated at all. Self-conscious +children will complain much of breathlessness and a sense of +suffocation, of headache, of palpitation, of intolerable itching, of +the pressure of clothing, or of flushing and a sense of heat. +Excessive introspection influences their conduct in many ways. At +children's parties, for example, they will be found wandering about +unhappy, dazed and unable to feel the reality of the surroundings +which afford such joy to the others; or they may be anxious to join in +play, but finding themselves called upon to take their turn are apt to +stand helplessly inactive, or to burst into tears. At school, though +they may be really quick to learn, they will often be found oblivious +of all that has gone on around them, not from stupidity, but from +inability to dissociate their thoughts from themselves and to +concentrate attention upon the matter in hand. In such a case we must +aim at developing the child's interest to the exclusion of this morbid +introspection. Taking advantage of his individual aptitude, we must +strengthen his hold upon externals in every way possible, and we must +explain to him the nature of his failing and teach him that his +salvation lies in cultivating his capacity for paying attention to +things around him and developing an interest in suitable occupations.</p> + +<p><span class="pagenum">Page 140<a name="Page_140" id="Page_140"></a></span> +Fainting fits are not uncommon amongst nervous children from about +the sixth year onwards, and are apt to give rise to an unwarranted +suspicion of epilepsy. In other cases fears have been aroused that the +heart may be diseased. In children who faint habitually the nervous +control of the circulation is deficient. We notice that when they are +tired by play, or when they are suffering from the reaction that +follows excitement of any sort, the face is apt to become pale, and +dark lines may appear under the eyes. Yet there may be no true anæmia +present: it is only that the skin is poorly supplied with blood for +the moment. After a little rest in bed, or under the influence of a +new excitement, the colour returns, and the tired look vanishes. If +children of this type are made to stand motionless for any length of +time, and if at the same time there is nothing to attract their +interest or attention—a combination of circumstances which unhappily +is sometimes to be found during early morning prayers at school—the +want of tone in the blood vessels may leave the brain so anaemic that +fainting follows. The first fainting attack is a considerable +misfortune, because the fear of a recurrence is a potent cause of a +repetition. Standing upright with the body at rest and the mind +vacant, the circulation stagnates, the boy's mind is attracted by the +suggestion, he fears that he will faint as he has done before, and he +faints. Schoolmasters are well aware that if one or two boys faint in +chapel and are carried out, the trouble may grow to the proportion of +a veritable epidemic. It is important +<span class="pagenum">Page 141<a name="Page_141" id="Page_141"></a></span> +that this habit of fainting +should be combated not only by general means to improve the tone of +the body and circulation, but also by taking care that the child +understands the nature of the fainting fit, and the part which +association of ideas plays in producing it. Disease of the heart +seldom gives rise to fainting.</p> + +<p>The same vasomotor instability which shows itself in the tendency to +syncopal attacks is apparent in many other ways. Sudden sensations of +heat and of flushing, equally sudden attacks of pallor, coldness of +the extremities, abundant perspiration,—raising in the mind of the +anxious mother the fear of consumption,—and excessive diuresis are +common accompaniments. A further group of symptoms is provided by the +extreme sensibility of the digestive apparatus. Dyspepsia, +hyperaesthesia of the intestinal tract, viscero-motor atonies and +spasms, and anomalies of the secretions, whether specific like that of +the gastric juice or indifferent like that of the nasal, pharyngeal, +gastric, and intestinal mucus, are all of common occurrence. Whenever +the nervous child is subjected to any exhausting experience, any +excitement, pleasurable or the reverse, or any undue exertion, whether +mental or physical, one may note the subsequent gastro-intestinal +derangement, including even a coating of the tongue. The slightest +deviation from the usual diet, the most trivial fatigue, a chill of +the body, even a change in the temperature of the food may set loose +the most extreme reactions in the gastro-intestinal tract—motor, +sensory, or secretory. +<span class="pagenum">Page 142<a name="Page_142" id="Page_142"></a></span> +It is not an accident that so often the mucous +diarrhoea, which may have afflicted an excitable child in London for +many months, and which a visit to the seaside, with all its healthy +activities, may seem to have completely cured, relapses within a day +or two of the return to the restricted environment and uninteresting +routine of life in London. The child who was happy and busy and at +peace with himself, at play in the open air, resents the sudden +cessation of all this, and the nervous unrest returns. To attempt +treatment by dietetic restrictions alone is to deal only with a +symptom. The gastro-intestinal reactions are so violent that the +parents are generally voluble on the subject of the many foods which +cannot be taken and the few which are not suspect. To prescribe rigid +tables of diet is to add to the alarm of the mother, and to sustain +her in the belief that the child is in daily danger of being poisoned +by a variety of common articles of diet. Only by lowering the +excitability of the nervous system, by occupying the mind and giving +strength to the child's powers of control can we effectively combat +the hyperaesthesia. If necessary the personnel of the management of +the child will have to be altered. There may be no other way to +achieve certain and rapid improvement in a condition which is causing +grave danger to the child and very genuine distress and suffering to +the parents. A violent reaction to intoxications of all sorts is a +further stigma of nervous instability. Sudden and even inexplicable +rises of temperature are frequent complaints, and the constitutional +<span class="pagenum">Page 143<a name="Page_143" id="Page_143"></a></span> +effects of even trivial local infections are apt to be +disproportionately great.</p> + +<p>Fatigue is easily induced and is exhibited in all varieties of +activity—mental, physical, or visceral. Mental work may produce +fatigue with extreme readiness even although the quality of the work +may remain of a high standard. To Darwin and to Zola work for more +than three hours daily was an impossibility, and yet their work done +under these restrictions excites all men's admiration. The palpitation +and breathlessness which follows upon trivial exertion, such as +climbing a flight of stairs, is a good example of visceral fatigue.</p> + +<p>Among adult neuropaths we recognise the harm which may be done by +unwise speeches on the part of relatives, or still more on the part of +doctors. A chance word from a doctor or nurse off their guard for the +moment will implant in the minds of many such a person the unyielding +conviction that he or she is suffering from some gastric complaint, +from some cardiac affection, or from some constriction of the bowel. +It may take the united force of many doctors to uproot this +pathological doubt which was implanted so easily and so carelessly. +The medical student is notoriously prone to recognise in himself the +symptoms of ailments which he hears discussed. Little children, too, +are apt to suffer in the same way. How much illness could be avoided +if mothers would cease to erect some single manifestation of +insufficient nervous control into a local disorder which becomes an +object of anxiety to the child and to the whole household.</p> + +<p><span class="pagenum">Page 144<a name="Page_144" id="Page_144"></a></span> +Undue liability to fatigue, irritability, instability, lack of +control over the emotions, extreme suggestibility, prompt and +exaggerated reactions to toxins of all sorts, excessive vasomotor +reactions and anomalies of secretion, weakness of the +gastro-intestinal apparatus—these, and many other symptoms, are of +everyday occurrence in the nervous child. To discuss them more fully +would be to pass too far from our nursery studies into a consideration +of psychological medicine.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 145<a name="Page_145" id="Page_145"></a></span></p> + +<h3>CHAPTER XI</h3> + +<h3>NERVOUSNESS AND PHYSIQUE</h3> +<p> </p> + +<p>It has already been said that symptoms of nervousness are often +accompanied by faults in the physical development of the child. The +defects may assume so many forms as to make any attempt at description +very difficult. Nevertheless, certain types of physical defect present +themselves with sufficient frequency, in combination with neurosis, to +merit a detailed description. For example, we recognise a type of +nervous child which is marked by a persistence into later childhood of +certain infantile characteristics of the build and shape of body. +Further, we meet with a group characterised by a special want of tone +in the skeletal muscles, by lordosis, by postural albuminuria, and by +abdominal and intestinal disturbances of various sorts. We recognise +also the rheumatic type of child with a tendency to chorea, and in +contrast to this a type with listlessness, immobility, and katatonia. +Lastly, in a few children, in boys as well as in girls, we may meet +with cases of hysteria.<a name="FNanchor_3_3" id="FNanchor_3_3" /><a href="#Footnote_3_3" class="fnanchor">[3]</a></p> + +<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3" /><a href="#FNanchor_3_3"> +<span class="label">[3]</span></a> If we accept as hysterical all symptoms which are +produced by suggestion and which can be removed by suggestion, we may +correctly speak of a physiological hysteria of childhood, which +includes a very large number of the symptoms discussed. The term is +used here in its older more limited sense.</p></div> + +<p><span class="pagenum">Page 146<a name="Page_146" id="Page_146"></a></span></p> + +<p class="subhead">(1) A Group with Persistence of Certain Infantile Characteristics</p> + +<p>During the first year or eighteen months of life, the rounded +infantile shape of body persists. The limbs are short and thick, the +cheeks full and rounded, the thorax and pelvis are small, the abdomen +relatively large and full. The great adipose deposit in the +subcutaneous tissue serves as a depôt in which water is stored in +large amounts. In the healthy child of normal development by the end +of the second year a great change has taken place. The shape of the +body has become more like that of an adult in miniature. The limbs +have grown longer and slimmer. The thorax and pelvis have developed so +as to produce relatively a diminution in the size of the abdomen. The +body fat is still considerable, but no longer completely obliterates +the bony prominences of the skeleton. Delay in this change, in this +putting aside of the infantile habit of body, is commonly associated +with a corresponding backwardness in the mental development. Such +children walk late, talk late, learn late to feed themselves, to bite, +and to chew effectively. Watery and fat, they carry with them into +later childhood the infantile susceptibility to catarrhal infections +of the lung, bowel, skin, etc., and they are apt to suffer, in +consequence, from a succession of pyrexial attacks. Nasal catarrh, +bronchitis, otitis media, enteritis, eczema, urticaria papulata, are +apt to follow each other in turn, giving rise in many cases to a +persistent enlargement +<span class="pagenum">Page 147<a name="Page_147" id="Page_147"></a></span> +of the corresponding lymphatic glands. The +effect upon the different tissues of the body of these repeated +infections is very various. We are probably not wrong in attributing +the failure to develop and the persistently infantile appearance to a +prejudicial effect upon the various ductless glands in the body. The +condition is associated with an excessive retention of fluid in the +body, secondary in all probability to alterations in the concentration +and distribution of the saline constituents of the body. A rapid +excretion of salts may be followed by a correspondingly speedy +dehydration of the body, a retention of salts by a sudden increase of +weight. The parathyroid glands are probably closely concerned in +regulating the retention and excretion of salts, and especially of +calcium, a circumstance which becomes of significance when we remember +how frequently rickety changes, tetany, and other convulsive seizures +form part of the clinical picture which we are now considering. While +it is difficult to determine the effect of repeated infections upon +the functions of the endocrine glands, we have clear evidence of the +deleterious influence upon almost all the tissues of the body, the +functioning of which it is more easy to estimate. For example, the +cells of the skin and of the mucous membranes which happen to be +visible to the eye show clear evidence of diminished vitality and +increased vulnerability. Physiological stimuli, incapable of producing +any visible reaction in healthy children, habitually determine widely +spread and persistent inflammatory reactions. For example, +<span class="pagenum">Page 148<a name="Page_148" id="Page_148"></a></span> +the licking movements of the tongue at the corners of the mouth produce +the little unhealthy fissures which the French call <i>perlèche</i>. The +physiological stimulus of the erupting tooth is capable of causing a +painful irritation of the gum, so that the child is said to suffer +from teething, accompanied, it may be, and the association is +significant, by "teething convulsions." The irritation of the urine +produces rawness and excoriation of the skin of the prepuce, contact +with intestinal contents not in themselves very abnormal, an +intractable dermatitis of the buttocks or a persistent diarrhoea and +enteral catarrh. Improvement in the general health, the result of the +cessation for the time being of the recurrent infections, perhaps +consequent upon improved hygienic conditions, always determines the +rapid disappearance of all these accompaniments of the general +diminution of tissue vitality.</p> + +<p>The muscular system and the bones are commonly also involved, so that +rickety changes are often found in these infantile and watery +children. In early childhood the processes of calcification and +decalcification proceed side by side and with great rapidity, and in +health there is always a balance on the side of the constructive +process. In the children whom we are now considering, saturated as +they are, from time to time, with the toxins resulting from repeated +infection, ossification may be so interfered with as to cause +softening and bending, with the evolution of a state of rickets. +Between bone and muscle, too, we find a close relationship. We do not +find powerful muscles with softened bone, +<span class="pagenum">Page 149<a name="Page_149" id="Page_149"></a></span> +nor flabby muscle with rigid and well-formed bone.</p> + +<p>In the nervous system, the conditions are somewhat different. In skin, +in bone, and in muscle new cell elements are constantly being formed, +and the life of the individual cell is relatively short. In the +nervous system, on the other hand, the individual cells are long +lived. Their life-history may even be coterminous with that of the +individual, and if destroyed they are not replaced. Nevertheless, they +do not escape undamaged in the general disturbance. In a deprivation +of calcium we have, in all probability, the explanation of the +increased irritability of peripheral nerves and of the tendency to +convulsive seizures of all sorts which is a common accompaniment of +the condition. Convulsions, laryngismus stridulus, tetany, or +carpopedal spasm are all frequently met with. In crying, the children +hold their breath to the point of producing extreme cyanosis, ending, +as the spasm relaxes, with a crowing inspiration, which resembles and +yet differs in tone from both the whoop of whooping-cough and the +crowing inspiration of croup.</p> + +<p>Apart, however, from this tendency to convulsive seizures the nervous +system of these children is abnormal. As a rule they are excitable, +and develop late the power to control their emotions. Lagging behind +in physical development and in the capacity to interest themselves in +the pursuits of normal children, their emotional state remains that of +a much younger child. In the infant classes at schools they are +recognised as dullards, learning +<span class="pagenum">Page 150<a name="Page_150" id="Page_150"></a></span> +slowly, speaking badly, and lacking co-ordination in all muscular movements.</p> + +<p>The clinical picture so depicted is encountered with extreme frequency +among the children of the poor in our large cities. To find a name for +the condition is no easy matter. To call it "rickets" is to place an +undue emphasis upon the bony changes which, though common, are by no +means invariable. Elsewhere I have suggested the name status +catarrhalis, on an analogy with the name status lymphaticus, which in +the post-mortem room is used to describe the secondary overgrowth of +lymphatic tissue which is found in these catarrhal children. In the +present connection it is of interest to us to note how commonly the +nervous system is involved in the general picture and the frequency +both of convulsive disorders and of neuropathy.</p> + +<p>The nervous symptoms of both sorts are to be allayed only by improving +the general hygiene of the child and raising its resistance against +infection. A sufficiency of fresh air and of sunlight, and a +management which encourages independence of action in the child, are +both necessary. The diet is of the first importance. It should be +sufficient, and no more than sufficient, to cover the physiological +needs of the child for food. The majority of these children have +enormous appetites, and excess of food, and especially of carbohydrate +food, plays some part in the production of the disturbance. We must +guard against overfeeding, against want of air and want of exercise, +and against those errors of management described in previous chapters, which +<span class="pagenum">Page 151<a name="Page_151" id="Page_151"></a></span> +produce the maximum of disturbance in this type of child.</p> + + +<p class="subhead">(2) A Group with Muscular Atrophy, Lordosis, and Postural Albuminuria</p> + +<p>At an older age, in children from the fifth year onwards, a second +type of physical defect associated with pronounced nervous disturbance +presents itself with some frequency. The body is thin and badly +nourished, and the muscular system especially poorly developed and +very lax in tone. The most striking feature is the extreme lordosis, +accompanied usually by a secondary and compensatory curve in the +cervico-dorsal region, so that the shoulders are rounded, with the +head poked forward. Viewed from in front the abdomen is seen to be +prominent, overhanging the symphysis pubis, while the shoulders have +receded far backwards. The scapulæ have been dragged apart, as though +by the weight of the dependent arms, with eversion of their vertebral +borders and lowering of the points of the shoulders. The position +which they adopt is that into which the body falls when it ceases to +be braced by strong muscular support. The muscular system is here so +weakly developed and so toneless that the posture is determined by the +bony structure and its ligamentous attachments.</p> + +<p>The lordosis resembles the similar deformity which develops in cases +of primary myopathy, when the spinal muscles have undergone complete +atrophy. As in myopathy the movements are +<span class="pagenum">Page 152<a name="Page_152" id="Page_152"></a></span> +very uncertain. The children are apt to fall heavily when the centre of gravity is +suddenly displaced, because their upright posture is maintained by +balancing the trunk upon the support of the pelvis. The frequency and +severity of the falls which these children suffer is a common +complaint of the mother. The faulty posture is often associated with +slight albuminuria. Its appearance is very capricious, but it is +dependent to a great extent upon the assumption of the erect posture. +There has been much discussion as to its explanation. It has been +argued that the lordosis itself produces the albuminuria by mechanical +compression of the renal vein, and it is said that albuminuria can be +produced, even in the prone position, by placing the child in a +plaster jacket applied so as to maintain the position of lordosis. +Other observers, however, have not obtained this result. It seems most +likely that the albuminuria is due to defective tone in the vasomotor +musculature, comparable in every way to the defective tone in the +muscles of the skeleton. We have often further evidence of vasomotor +weakness. Fainting attacks are so common as to be the rule rather than +the exception. Again, mothers are likely to complain of the child's +pallor and of dark lines under the eyes, especially after exertion or +in the reaction which follows excitement of any sort. As a rule a +blood count will not show any very striking evidence of true anæmia. +The pallor is of vasomotor origin, determined by faults in the +distribution of the blood from vasomotor weakness and not by deficient +<span class="pagenum">Page 153<a name="Page_153" id="Page_153"></a></span> +blood formation. Circulatory and vasomotor disturbance probably also +accounts for the dyspeptic pains and vomiting which commonly accompany +any emotional excitement, or follow any unusual exertion or fatiguing +experience. Constipation is a common, and mucous diarrhoea an +occasional, symptom. The abdomen is often pigmented. The hands and +feet are usually cold and cyanosed.</p> + +<p>The extreme nervousness of the children is the point upon which most +stress may be laid in the present connection. The association of +albuminuria with neurosis in childhood has been noticed by many +observers. The gastric and intestinal symptoms are especially +characteristic. If the condition of the children is not materially +improved, and if the symptoms, both of the physical defect and of the +nervous disturbance, are not cut short, we may predict that in adult +age their lives will be made miserable by a variety of abdominal +symptoms dependent both on the vasomotor disturbance and upon the +accompanying neurosis. Now that surgery forms so large a part of our +therapeutic proceedings, they may not reach middle life without being +submitted to one or more surgical operations. With good management +both on the physical side and on the moral or psychological side they +can be made into strong and useful members of society.</p> + +<p>The treatment of these cases may be summed up as follows:</p> + +<p><i>(a)</i> We must search for any source of infection, a source which is +often to be found in the condition +<span class="pagenum">Page 154<a name="Page_154" id="Page_154"></a></span> +of the tonsils. Enucleation may then be indicated as the first step in treatment.</p> + +<p><i>(b)</i> Massage and gymnastic exercises calculated to improve the +muscular tone, while every effort is made to secure for the child as +perfect hygiene in the environment as possible.</p> + +<p><i>(c)</i> The stimulating effect of cold douches is often very evident in +improving the vasomotor tone. These children, however, will not stand +well the abstraction of heat from their thin and chilly little bodies, +so that it is a good plan before the colder douche to immerse the +child in a hot bath and to return again to the bath momentarily +afterwards. With these precautions children will often enjoy a cold +spray, the temperature of which may be constantly lowered as they +become used to it. Prolonged hot bathing has a correspondingly +prejudicial effect.</p> + +<p><i>(d)</i> We must be on the watch to prevent the development of further +postural deformities, such as scoliosis. If a child of strong muscular +tone and good physique habitually adopts some posture, curled up, it +may be, in some favourite easy-chair, there is little likelihood that +its constant assumption will produce deformity. When the muscular +system is lax and weak, on the other hand, deformity such as scoliosis +is very readily caused. It is important, for example, to see that the +child does not habitually incline to one side in reading or writing. +When there is little energy for free and energetic play the children +are apt to become great bookworms. If there is shortsightedness, the +dangers are correspondingly +<span class="pagenum">Page 155<a name="Page_155" id="Page_155"></a></span> +increased. A special chair may be made +with a well-fitting back and the seat a little tilted upwards so as to +throw the child's trunk on to the support of the back. Lastly, a desk, +the height of which can be regulated at will, can be swung into the +proper position. The child, sitting straight and square, with the +weight supported by the foot-rest and back as well as by the seat of +the chair, should be taught to write with an upright hand, avoiding +the slope which leads to sitting sideways with the left shoulder +lowered.</p> + +<p>(e) Malt extract, cod liver oil, Parrish's food, and other tonics may +be of undoubted service.</p> + + +<p class="subhead">(3) Rheumatism and Cholera</p> + +<p>It is certain that there is a close association between rheumatism in +childhood and the common nervous affection known as chorea. We are +still ignorant of the precise nature of the infection which we know as +rheumatism. There is much to suggest that in rheumatism we have to +deal only with a further stage in those catarrhal infections to which +so much infantile ill-health is to be attributed, and that +endocarditis and arthritis, when they arise, signalise the entry of +these catarrhal, non-pyogenic organisms into the blood stream, +overcoming at last the barrier of lymphoid tissue which has +hypertrophied to oppose their passage. Certainly the connection of +rheumatism with catarrhal infections of the mucous membranes and +adenoid enlargements +<span class="pagenum">Page 156<a name="Page_156" id="Page_156"></a></span> +of all sorts is a close one. Whatever its +nature, the rheumatic infection in childhood is more lasting and +chronic than in adult life. Rheumatism in childhood is not manifested +by acute and short-lived attacks of great severity so much as by a +long-continued succession of symptoms of a subacute nature, a +transient arthritis, perhaps, succeeding an attack of sore throat with +torticollis, to be followed by carditis, to be followed again by +another attack of tonsillitis. And so the cycle of symptoms revolves. +In most cases the child grows thin and weak; in most cases he becomes +restless, irritable, and unhappy; often there is definite chorea. Of +this cerebral irritability chorea is the expression. In adults, chorea +is perhaps more obviously associated with mental stress of all sorts +and with states of excitement and agitation. In the case of little +children it is often only the mother who really appreciates how +radical an alteration the child's whole nature has undergone, and how +great the element of nervous overstrain has been before the chorea has +appeared.</p> + +<p>Of the treatment of chorea there is no need to speak. It is purely +symptomatic. Isolation, best perhaps away from home, as might be +expected, gives the best results. If there are pronounced rheumatic +symptoms, the salicylates will be needed; if there is anæmia, arsenic +and iron; if there is sleeplessness and great restlessness, bromides +or chloral. Hypnotism is often almost instantly successful, but, apart +from hypnosis, curative suggestions +<span class="pagenum">Page 157<a name="Page_157" id="Page_157"></a></span> +proceeding from the attendants +form the principal means at our disposal.</p> + + +<p class="subhead">(4) Exhaustion and Katatonia</p> + +<p>A large number of children, in convalescence from infective disorders, +when the nutrition of the body has fallen to a low ebb, show as +evidence of cerebral exhaustion a group of symptoms which in a sense +are the reverse of those which characterise cerebral irritation and +chorea. The healthy child is a creature of free movement. The children +we are now considering will sit for a long time motionless. The +expression of their faces is fixed, immobile, and melancholy. If the +arm or leg is raised it will be held thus outstretched without any +attempt to restore it to a more natural position of rest for minutes +at a time. The posture and expression remind us at once of the +katatonia which is symptomatic of dementia præcox and other stuporose +and melancholiac conditions in adult life. Symptoms of this sort are +especially common in children with intestinal and alimentary +disturbances of great chronicity.</p> + +<p>The symptom is so frequently met with that it is strange that it +should have attracted so little attention as compared with the +contrasting condition of chorea. And yet it is of more serious +significance, more difficult to overcome, and with a greater danger +that permanent symptoms of neurasthenia will result. In early +childhood a careful dietetic régime, suitable hygienic surroundings, +and a stimulating +<span class="pagenum">Page 158<a name="Page_158" id="Page_158"></a></span> +psychical atmosphere will often effect great +improvement. As in chorea, however, relapses are frequent, and there +are cases which for some unexplained reason are peculiarly resistant +to all remedial influences.</p> + + +<p class="subhead">(5) Hysteria</p> + +<p>In hysteria, in contrast to the types previously described, the +infective element may be completely absent. Except in some special +features of minor importance the symptoms of hysteria do not differ +from those of adults, and, as in adult age, the condition of hysteria +may be present although the physical development may be perfect. We +cannot here speak of any physical characteristics which are associated +with the nervous symptoms.</p> + +<p>The third or fourth year represents the age limit, below which +hysterical symptoms do not appear. Thereafter they may be occasionally +met with, with increasing frequency. At first, in the earlier years of +childhood, there is no preponderance in the female sex. As puberty +approaches, girls suffer more than boys.</p> + +<p>It may be said to be characteristic of hysteria in childhood that its +symptoms are less complex and varied than in adult life. The naive +imagination of the child is content with some single symptom, and is +less apt to meet the physician half-way when he looks for the +so-called stigmata. Similarly mono-symptomatic hysteria is +characteristic of oases occurring in the uneducated or peasant class. +<span class="pagenum">Page 159<a name="Page_159" id="Page_159"></a></span> +In children, hysterical pain, hysterical contractures or palsies, +mutism, and aphonia are the most usual symptoms. Hysterical deafness, +blindness, and dysphagia are manifestations of great rarity in +childhood.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 160<a name="Page_160" id="Page_160"></a></span></p> + +<h3>CHAPTER XII</h3> + +<h3>THE NERVOUS CHILD IN SICKNESS</h3> +<p> </p> + +<p>In time of sickness the management of the nervous child becomes very +difficult. Restlessness and opposition may reach such a pitch that it +may be almost impossible to confine the patient to bed or to carry out +the simplest treatment. Sometimes days may elapse before the +sick-nurse who is installed to take the place of the child's usual +attendant is able to approach the cot or do any service to the child +without provoking a paroxysm of screaming. In such a case any +systematic examination is often out of the question, with the result +that the diagnosis may be delayed or rendered impossible. There is +only one reassuring feature of a situation, which arises only in +nurseries in which the management of the children is at fault; the +doctor has learned from experience that this pronounced opposition of +the child to himself, to the nurse, and even to the mother, is of +itself a reassuring sign, indicating, as a rule, that the condition is +not one of grave danger or extreme severity. When the child is more +seriously ill, opposition almost always disappears, and the child lies +before us limp and +<span class="pagenum">Page 161<a name="Page_161" id="Page_161"></a></span> +passive. Only with approaching recovery or +convalescence does his spirit return and renewed opposition show +itself.</p> + +<p>Extreme nervousness in childhood carries with it a certain liability +towards what is known as "delicacy of constitution." The sensitiveness +of the children is so great that they react with striking symptoms to +disturbances so trivial that they would hardly incommode the child of +more stable nervous constitution. For example, a simple cold in the +head, or a sore throat, may cause a convulsion or a condition of +nervous irritability which may even arouse the suspicion that +meningitis is present. Or, again, a little pharyngeal irritation which +would ordinarily be incapable of disturbing sleep may be sufficient to +keep the child wide awake all night with persistent and violent +coughing. The little irritating papules of nettlerash from which many +children suffer are commonly disregarded by busy, happy children +during the day, and even at night hardly suffice to cause disturbance. +The nervous child, on the other hand, will scratch them again and +again till they bleed, tearing at them with his nails, and making deep +and painful sores.</p> + +<p>The temperature is commonly unstable and readily elevated. Moreover, +feverishness from whatever cause is often accompanied by an active +delirium, which is apt to occasion unnecessary alarm. This symptom of +delirium is always a manifestation of an excitable temperament. I +remember being called to see a young woman who +<span class="pagenum">Page 162<a name="Page_162" id="Page_162"></a></span> +was thought to be suffering from acute mania. +Examination showed that she was suffering +from pneumonia in the early stages. It was only later that we +discovered that she had always been of an unstable nervous +temperament, and had been in an asylum some years before. Those of us +who are fortunate in possessing a placid temperament and have +developed a high degree of self-control are not likely to show +delirium as a prominent symptom should we fall ill with fever; just as +we should not struggle and scream too violently when we "come round" +from having gas at the dentist's. Looked at from this point of view, +it is natural for all children to become delirious readily, and this +tendency is peculiarly marked in those who are unduly nervous.</p> + +<p>As a consequence of this extreme sensitiveness, the nervous child is +likely to suffer more than others from a succession of comparatively +trifling ailments and disturbances. The delicacy of the child has, in +this sense, a real existence, and is not confined to the imagination +of over-anxious and apprehensive parents. No doubt the nervous mother +of an only child does worry unnecessarily, and is far too prone to +feed her fears by the daily use of the thermometer or the +weighing-machine; but her friends who are happy in the possession of +numerous and placid children are not justified in laying the whole +blame upon her too great solicitude. Children who are members of large +families, whose nervous systems have been strengthened by contact with +their brothers and sisters, are not habitually +<span class="pagenum">Page 163<a name="Page_163" id="Page_163"></a></span> +upset by trifles, and suffer even serious illnesses with symptoms of less severity. +Nervous children, and only children, on the other hand, show the opposite +extreme. Nevertheless, the mother of a nervous and delicate child—a +child, that is to say, who, even if he is not permanently an invalid, +nevertheless never seems quite well and lacks the robustness of other +children—should realise clearly how much of this sensitiveness is due +to the atmosphere of unrest and too great solicitude which surrounds +him. It is a matter of universal experience that excess of care for +only children has a depressing influence which affects their +character, their physical constitution, and their entire vitality. At +all costs we must hide our own anxieties from the child, and we must +treat his illnesses in as matter-of-fact a way as possible.</p> + +<p>When illness comes, his daily routine should be interrupted as little +as possible. In dealing with nervous children, it is often better to +lay aside treatment altogether rather than to carry out a variety of +therapeutic procedures which have the effect of concentrating the +child's mind upon his symptoms. When we grown-up people are sick, we +often find a great deal of comfort in submitting ourselves to some +form of treatment. We have great faith, we say, in this remedy or in +that. It is <i>our</i> remedy, a <i>nostrum</i>. The physician knows well that +the opportunities which are presented to him of intervening +effectually to cut short the processes of disease by the use of +specific cures are not very numerous, and that often enough the +justification +<span class="pagenum">Page 164<a name="Page_164" id="Page_164"></a></span> +for his prescription is the soothing effect which it +may exercise upon the mind of the patient, who, believing either in +the physician or in his remedy, finds confidence and patience till +recovery ensues. As a rule this form of consolation is denied to +little children. They have no belief in the efficacy of the remedies +which are applied with such vigour and persistence. Indeed, it is not +the child, but his anxious mother, who finds comfort in the thought +that everything possible has been done. Therefore, a prescription must +be written and changed almost daily, the child's chest must be +anointed with oil, and the air of the sick-room made heavy with some +aromatic substance for inhalation, and all this when the disturbance +is of itself unimportant, and owes its severity only to the undue +sensitiveness of the child's nervous system.</p> + +<p>The very name of illness should be banished from such nurseries. +Everything should be done to reassure the child and to make light of +his symptoms, and we can keep the most scrupulous watch over his +health without allowing him to perceive at all that our eye is on him. +With older children the evil results of suggestions, unconsciously +conveyed to them by the apprehension of their parents, become very +obvious. The visit of the doctor, to whom in the child's hearing all +the symptoms are related, is often followed by an aggravation which is +apt to be attributed to his well-meant prescription. The harm done by +examinations, which are specially calculated to appeal to the child's +imagination, as, for instance, an X-ray examination, +<span class="pagenum">Page 165<a name="Page_165" id="Page_165"></a></span> +is often clearly apparent. I remember a schoolboy of thirteen who was sent to me +because he had constantly complained of severe abdominal pain. He was +a nervous child with a habit spasm, the son of a highly neurotic +father and an overanxious mother. An X-ray examination was made, but +showed nothing amiss. The child's interest and preoccupation in the +examination was painfully obvious. That night his restraint broke down +altogether, and he screamed with pain, declaring that it had become +insupportable. Younger children, less imaginative but equally +perverse, noticing how anxiously their mothers view their symptoms, +will often make complaint merely to attract attention and to excite +expressions of pity or condolence. Sometimes they will enforce their +will by an appeal to their symptoms. I have had a little patient of no +more than thirteen months of age who suffered severely and for a long +time from eczema, and who in this way used his affliction to ensure +that he got his own way. If he was not given what he wanted +immediately he would fall to scratching, with an expression upon his +face which could not be mistaken. To him, poor child, the grown-up +people around seemed possessed of but one desire—to stop his +scratching; and he had learnt that if he showed himself determined to +scratch they would give way on every other point.</p> + +<p>The ill-effects of departing too readily from ordinary nursery routine +on account of a little illness, and of adopting straightway a variety +of measures of treatment, is well shown in cases of +<span class="pagenum">Page 166<a name="Page_166" id="Page_166"></a></span> +asthma in children. The asthmatic child is almost always of a highly nervous +temperament, and often passionate and ungovernable. Often the most +effective treatment of an attack, which usually comes on some hours +after going to bed, is to make little of it, to talk naturally and +calmly to the child, to turn on the light, and to allow him, if he +will, to busy himself with toys or books. To be seized with panic, to +send post-haste for the doctor, to carry the patient to the open +window, to burn strong-smelling vapours, and so forth, not only is apt +to prolong the nervous spasm on this occasion, but makes it likely +that a strong impression will be left in his mind which by +auto-suggestion will provoke another attack shortly. With nervous +children a seeming neglect is the best treatment of all trivial +disorders. Meanwhile we can redouble our efforts to remedy defects in +management, and to obtain an environment which will gradually lower +the heightened nervous irritability.</p> + +<p>When the illness is of a more serious nature, as has been said, the +restlessness as a rule promptly disappears. In each case it must be +decided whether it is best for the child to be nursed by his mother +and his own nurse, or by a sick-nurse. In the latter event the +ordinary nurse and the mother should absent themselves from the +sick-room as much as possible. Often the firm routine of the hospital +nurse is all that is wanted to obtain rest. Less often, the child will +be quiet with his own nurse, and quite unmanageable with a stranger.</p> + +<p>There is, however, another side to the question. +<span class="pagenum">Page 167<a name="Page_167" id="Page_167"></a></span> +The relation of neurosis in childhood to infection of the body is complex. +I have said that with the nervous child a trivial infection may produce symptoms +disproportionately severe. Persistent and serious infection, however, +is capable of producing nervous symptoms even in children who were not +before nervous, and we must recognise that prolonged infection makes a +favourable soil for neuroses of all sorts. The frequency with which +St. Vitus's dance accompanies rheumatism in childhood forms a good +example of this tendency. The child who, from time to time, complains +of the transient joint pains which are called "growing pains," and who +is found by the doctor to be suffering from subacute rheumatism, is +commonly restless, fretful, and nervous. Appetite, memory, and the +power of sustained attention become impaired. Often there is excessive +emotional display, with, perhaps, unexplained bursts of weeping. The +child is readily frightened, and when sooner or later the restless, +jerky movements of St. Vitus's dance appear, the usual explanation is +that some shock has been experienced, that the child has seen a street +accident, has been alarmed by a big dog jumping on her, or by a man +who followed her—shocks which would have been incapable of causing +disturbance, and which would have passed almost unappreciated had not +the soil been prepared by the persistent rheumatic infection.</p> + +<p>The management of the nervous child whose physical health remains +comparatively good is difficult enough, but these difficulties are increased +<span class="pagenum">Page 168<a name="Page_168" id="Page_168"></a></span> +many times when the physical health seriously fails. To +steer a steady course which shall avoid neglecting what is dangerous +if neglected, and overemphasising what is dangerous if +over-emphasised, calls for a great deal of wisdom on the part both of +the mother and her doctor.</p> + +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 169<a name="Page_169" id="Page_169"></a></span></p> +<h3>CHAPTER XIII</h3> + +<h3>NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS</h3> +<p> </p> + +<p>In this chapter I approach with diffidence a subject which is rightly +enough occupying a great deal of attention at the present time: the +instruction of our children in the nature, meaning, and purpose of +sexual processes. It is a subject filled with difficulties. Every +parent would wish to avoid offending the sense of modesty which is the +possession of every well-trained child, and finds it difficult to +escape the feeling that discussion on such matters may do more harm +than good. There is certainly some risk at the present time that, +putting reticence on one side, we may be carried too far in the +opposite direction. The evils which result from keeping children in +ignorance are well appreciated. We have yet to determine the effect +upon them of the very frank and free exposure of the subject which is +recommended by many modern writers. Nevertheless, it must be granted +that it is not right to allow the boy or girl to approach adolescence +without some knowledge of sex and the processes of reproduction. If +nothing is said on such subjects, which in the nature of things are bound +<span class="pagenum">Page 170<a name="Page_170" id="Page_170"></a></span> +to excite a lively interest and curiosity in the minds of older +children, evil results are apt to follow. Because parents have never +mentioned these subjects to their child, they must not conclude that +he is ignorant of all knowledge concerning them. It is not unlikely +that the question has often occupied his thoughts, and that his +speculations have led him to conclusions which are, on the whole, +true, although perhaps incorrect in matters of detail. Most children, +unable to ask their mother or father direct questions upon matters +which they feel instinctively are taboo, have pieced together, from +their reading and observation, a faulty theory of sexual life. The +pursuit of such knowledge, in secret, is not a healthy occupation for +the child. His parents' silence has given him the feeling that the +unexplored land is forbidden ground. In satisfying his curiosity he is +most certainly fulfilling an uncontrollable impulse, but he has been +forced to be secretive, and to look upon the information he has +acquired as a guilty secret. So far even the best of children will go +upon, the dangerous path. If training has been good, and if the child +has responded well to it, he will go no further. Though he can hardly +be expected to refrain from constructing theories and from testing +them in the light of any chance information which may come his way, he +will instinctively feel that the subject is one best left alone. He +will not talk of it with other boys—not even with those who are older +than himself and whose superior knowledge in all other matters he is +accustomed to respect. +<span class="pagenum">Page 171<a name="Page_171" id="Page_171"></a></span> +We need not be surprised, however, that the +majority of children do not attain to this high standard of conduct, +and that the interest and excitement of exploring the unknown and the +forbidden proves too great. Children will consult with each other +about such matters, and knowledge of evil may spread rapidly from the +older to the younger. In some schools, as is well known, there may +grow up with deplorable facility an unhealthy interest in sexual +matters. On the surface of school life all may seem fair enough, but +beneath, hidden from all recognised authority, lies much that is +unspeakable. If the boy has not been taught to have clean thoughts +upon matters which are essentially clean, if he has not learned to +know evil that he may avoid it, he may not escape great harm. The +fault in us which kept him in ignorance will recoil upon our own +heads. He will maintain the barrier which was erected in the first +place by our own unhappy reticence, and we may find it a hard task to +penetrate behind it and prevent his constant return to secret thoughts +and imaginings or secret habits and practices. Certain physiological +processes come to have for him an unclean flavour which is yet +perniciously attractive. He knows little of the real meaning of sexual +processes or of the great purpose for which they are designed. It is +only that an unhealthy interest becomes attached to all subjects which +are scrupulously avoided in general conversation. In secret he +develops a wrong attitude to all these matters.</p> + +<p><span class="pagenum">Page 172<a name="Page_172" id="Page_172"></a></span> +Oliver Wendell Holmes<a name="FNanchor_4_4" id="FNanchor_4_4" /> +<a href="#Footnote_4_4" class="fnanchor">[4]</a> tells us that in religion certain words and +ideas become "polarised," that is to say, charged with forces of +powerful suggestion, and must be "depolarised."</p> + +<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4" /><a href="#FNanchor_4_4"> +<span class="label">[4]</span></a> <i>The Professor at the Breakfast Table</i>, Oliver Wendell +Holmes.</p></div> + +<hr style="width: 45%;" /> + +<p>"I don't know what you mean by 'depolarising' an idea, said the +divinity-student.</p> + +<p>"I will tell you, I said. When a given symbol which represents a +thought has lain for a certain length of time in the mind, it +undergoes a change like that which rest in a certain position gives to +iron. It becomes magnetic in its relations—it is traversed by strange +forces which did not belong to it. The word, and consequently the idea +it represents, is polarised.</p> + +<p>"The religious currency of mankind, in thought, in speech, and in +print, consists entirely of polarised words. Borrow one of these from +another language and religion, and you will find it leaves all its +magnetism behind it. Take that famous word, O'm, of the Hindoo +mythology. Even a priest cannot pronounce it without sin; and a holy +Pundit would shut his ears and run away from you in horror, if you +should say it aloud. What do you care for O'm? If you wanted to get +the Pundit to look at his religion fairly, you must first depolarise +this and all similar words for him. The argument for and against new +translations of the Bible really turns on this. Scepticism is afraid +to trust its truths in depolarised words, and so cries out against a +new translation. I think, myself, if every idea +<span class="pagenum">Page 173<a name="Page_173" id="Page_173"></a></span> +our Book contains could be shelled out of its old symbol and put into a new, +clean, unmagnetic word, we should have some chance of reading it as +philosophers, or wisdom-lovers, ought to read it—which we do not and +cannot now, any more than a Hindoo can read the 'Gayatri' as a fair +man and lover of truth should do."</p> + +<hr style="width: 45%;" /> + +<p>Now in the minds of many boys and some girls certain words and ideas +connected with certain physiological processes become polarised. It is +the parents' duty to depolarise them. It is a task which cannot well +be deputed to others; nor can much help be derived from books, though +many have been written with the object of initiating children into the +mysteries of sex. No one but a parent is likely to be on sufficiently +intimate terms with the child to enable the subject to be approached +without restraint or awkwardness, and no book can adapt itself to the +varying needs of individual children. An exposition in cold print, or +a single formal lecture on the subject, is apt to do more harm than +good. I have seen instructions to parents to deliver themselves of set +speeches, examples of which are given, which seem to me well +calculated to repel and frighten the nervous child. Still more +dangerous is the advice to make sexual hygiene a subject for class +study. The task requires that parents should be upon very intimate +terms with their children, and on suitable occasions, when this +feeling of intimacy is strong, children should be encouraged to speak +freely and to ask for explanations. +<span class="pagenum">Page 174<a name="Page_174" id="Page_174"></a></span> +By a judicious use of such opportunities piece by piece the whole may be unfolded. +In order that the child may approach the subject in the proper spirit we may +stimulate interest by a few lessons in Natural History. A child of +eight or ten years of age is not too young to learn a little of the +outlines of anatomy and physiology. If he is told a few bald facts +about the skeleton, about the circulation and the processes of +digestion such as any parent can teach at the cost of a few hours' +study of a handbook, this will lead naturally enough, in later +lessons, to a similar talk upon the excretory organs, reproduction, +and the anatomy and processes of sex, suitable to the individual. To +achieve "depolarisation," there is nothing more efficacious than the +frankness and explicitness of scientific statement, however +elementary. Later a little knowledge of Botany and Zoology will enable +a parent to sketch briefly the outlines of fertilisation and +reproduction. The child may grasp the conception that the life of all +individual plants and animals is directed towards the single aim of +continuing the species. He can be told how the bee carries the male +pollen to the female flower, how all living things habitually +conjugate, the lowest in the scale of development as well as the +highest, and how the fertilised egg becomes the embryo which is +hatched by the mother or born of her. As the child grows older and +understands more and more of these natural processes an opportunity +can be used to make the presentation of the subject more personal. He +can be told that during childhood his own sexual +<span class="pagenum">Page 175<a name="Page_175" id="Page_175"></a></span> +processes have been +undeveloped, but that as he grows older they will awake. That with +their awakening in adolescence new temptations to self-indulgence in +thought or action may assail him, but that these temptations are +delayed by the wisdom of Nature until his understanding has grown and +his man's strength of character has developed. A high ideal of purity +should be set before boy and girl alike, and the conception of sex +from the beginning should be associated in their minds with the high +purpose to which some day it may be put. Before the boy goes to a +boarding-school he should have imbibed from his father the desire for +moral cleanliness, the knowledge of good and of evil, and a cordial +dislike for everything that is sensual, self-indulgent, or nasty. +Talks on such subjects should be very infrequent, but I believe that, +if "depolarisation" is to be achieved, they must be repeated every now +and then during later childhood and in adolescence. To attempt to +impart all this interesting information in a single constrained and +awkward interview is to court failure, or at least to run the risk +that the explanation is not fully understood, so that the child is +mystified, or even offended in his sense of propriety.</p> + +<p>I have dwelt at some length upon this question of sex education, +because it is one of especial difficulty when we have to deal with a +child of nervous inheritance, or with a child in whom symptoms of +neurosis have developed in a faulty home environment. Misconduct in +sexual matters is a sign of deficient nervous and moral control, and when the +<span class="pagenum">Page 176<a name="Page_176" id="Page_176"></a></span> +conduct in other respects is ill-regulated, the development +of sexual processes must be watched with some anxiety. There are those +who see a still more intimate relationship between errors of conduct +or symptoms of neurosis in childhood and the sexual instincts.</p> + +<p>It is perhaps necessary here briefly to refer to the teaching of +Sigmund Freud of Vienna, because his views have attracted a great deal +of attention in this country and have become familiar to a great part +of the reading public. Freud believes that the origin of many abnormal +mental states and of the disturbances of conduct which are dependent +upon them is to be traced back to forgotten experiences, the +recollection of which has faded from the conscious mind, but which are +still capable of exerting an indirect influence. He regards the +process of forgetting, not as merely a passive fading of mental +impressions, but as an active process of repression, by which the +experience, and especially the unpleasant experience, is thrust and +kept out of consciousness. There thus arises a mental conflict between +the forces of repression and the forces which tend to obtrude the +recollection into consciousness, and at times the energy engendered in +this conflict escapes from the censorship of the repressing forces and +finds vent in the production of abnormal mental states or disorders of +conduct. Thus to take a simple example, a business man who has had a +trying day at the office, on returning home in the evening may succeed +in thrusting out of his consciousness the thought of his +disappointments and worries, +<span class="pagenum">Page 177<a name="Page_177" id="Page_177"></a></span> +yet the disturbance in his mind may show itself in quarrels with his wife +or complaints of the quality of the cooking at dinner.</p> + +<p>Freud has called attention to the part which the suppressed and +long-forgotten experiences of early childhood play in the production +of neuroses of all sorts at a later date, and he has laid especial +emphasis on sexual experiences as peculiarly fruitful causes of such +disturbances. Those who have embraced Freud's teaching have gone even +farther than he in this direction, and by psycho-analysis—that is to +say, by attempting in intimate conversation to arouse the dormant +memory and lay bare the buried complex, the suppression of which has +produced the conflict in the mind of the sufferer—will seldom fail to +discover the influence of sexual forces and sexual attractions which, +while capable of causing disorders of mind and of conduct, show +themselves only obscurely and indirectly, as, for example, in dreams +or in symbolic form.</p> + +<p>So far as the nervous disorders of children are concerned, much that +is written to-day upon the influence of repressed sexual experiences +may be dismissed as grotesque and untrue. The conclusions to which the +psycho-analyst is habitually led, and which he puts forward with such +confidence, can be convincing only to those who have replaced the +study of childhood by the study of the writings of Freud and his +school. Thus it is common enough to find a mother complaining that her +child of two or three years of age is bitterly jealous of the new baby +who has come to share with him his mother's love and attention. +<span class="pagenum">Page 178<a name="Page_178" id="Page_178"></a></span> +According to the views of Freud, we are to recognise in this jealousy +an exhibition of the sexual instincts of the older child, who scents a +possible rival for the affections of his mother. Even if we give to +the term sexual the widest possible meaning, it is difficult for a +close observer of children to detect any truth in this conclusion. The +behaviour of the older child to the newly born will be determined +mainly by the attitude adopted by the grown-up persons around him and +by the unconscious suggestions which his impressionable mind receives +from them. If the mother is fearful of what may happen, and refuses to +leave the children alone, she will find it hard to hide from the older +child her conviction that danger is to be apprehended from him. If +this suggestion acts upon his mind, and if the reputation that he is +jealous of the new baby becomes attached to him, he will assuredly not +fail to act up to it, and her daily conduct will appear to prove the +justness of his mother's apprehension. Fortunately, mothers are +commonly able to divest themselves of such fears as these. The older +child is brought freely to the baby to admire him, to bestow caresses +on him, and to speak to him in the very tones of his elders. In a few +days his reputation is established, that he is "so fond of the baby," +and to this reputation too he faithfully conforms. We have seen in an +earlier chapter that constantly and ostentatiously to oppose a child's +will is to produce a counter-opposition which because of its +persistence and vigour appears to have behind it the strongest +possible concentration of mind and power of will. +<span class="pagenum">Page 179<a name="Page_179" id="Page_179"></a></span> +Yet if we cease to oppose, the counter-opposition which appeared so formidable +at once dissolves, and the difficulty is at an end. We took as an example the +child's apparent determination to approach as near as possible to the +fire, the one place in the room which our fear of accident forbids +him. The difficulty with the new baby is but another example of the +same tendency. If he does not know that the ground is forbidden, if we +do not concentrate his attention on the prohibition, he will show no +particular desire to approach it. His apparent jealousy of his little +brother is the result not of the rivalry of sex, but of bad +management.</p> + +<p>Again, it is occasionally a subject of complaint that children will +apparently dislike their father, that they will shrink from him or +burst into tears whenever he approaches them. There is no need to see +in this the child's jealousy of the father as a rival in the +affections of his mother, which is the explanation proffered by the +school of Freud. Every action and every occupation of the child during +the whole day can be made a pleasure or a pain to him, according to +the attitude of his nurse and mother towards it. Eating and drinking +should be pleasant and are normally pleasant. The same forces which +are sufficient to make every meal-time a signal for struggling and +tears, are sufficient to produce this dislike, apparently so +invincible, to the father of his being.</p> + +<p>Although the nervous troubles of infancy are not commonly due, as +Freud and his numerous followers would have us believe, to suppressed +sexual desires +<span class="pagenum">Page 180<a name="Page_180" id="Page_180"></a></span> +or experiences, it is clear that in the sensitive mind +of the child the reception of a severe shock may have effects long +after the memory of it has disappeared from consciousness. In a +medical journal there was recently recounted the case of an officer of +the R.A.M.C. who all his life had suffered from claustrophobia—the +fear of being shut up in a closed space. By skilful questioning, the +remembrance of a terrifying incident in his childhood was regained. As +a child of five he had been shut in a passage in a strange house by +the accidental banging to of a door, unable to escape from the +attentions of a growling dog. A complete cure was said to follow upon +the discovery that in this incident lay the origin of the phobia. +Nevertheless, observation would lead me to lay the greater stress not +upon any one particular shocking or terrifying experience, but upon +the attitude of parents and nurses in focusing the child's attention +upon the danger, and in sapping his confidence by showing their own +apprehensions and communicating them to him.</p> + +<p>As a method of treatment for neuroses of childhood, psycho-analysis is +not only unsuccessful, it has dangers and produces ill effects which +far outweigh any advantage which may be gained from it.</p> + +<p>There can be no doubt that Freud has exaggerated the part which sexual +impulses play in causing neurosis. It will be sufficient for us to +recognise that for the nervous child the sexual life has especial +dangers, and we should redouble our efforts to +<span class="pagenum">Page 181<a name="Page_181" id="Page_181"></a></span> +prevent his ideas on the subject becoming "polarised." +For the child whose environment has been well regulated and who has developed +strength of character, self-control, and self-respect, there need be no fear.</p> + +<p> </p> +<p> </p> +<p><span class="pagenum">Page 182<a name="Page_182" id="Page_182"></a></span></p> +<h3>CHAPTER XIV</h3> + +<h3>THE NERVOUS CHILD AND SCHOOL</h3> +<p> </p> + +<p>At the onset of puberty childhood comes to an end, and the period of +adolescence begins. Into these further stages of development it is not +proposed to enter, but it may be well to consider a question which is +apt to present itself for answer at this period: "Should the boy, or +girl, of nervous temperament, or whose development up to this point +has been accompanied by symptoms of nervous disorder, be sent to a +boarding-school?" So long as the child remains at home the home +environment is the force which alone is concerned in moulding his +character. We have seen how plastic the young child is, how imitative, +how suggestible, how prone to form habits good or bad. The diversity +of type shown by the homes is reflected in the diversity of character +and conduct exhibited by the children. The home is the culture medium, +and in no two homes is its composition the same. For each child home +influence remains to a great extent unchanged, and in great part +unchangeable. Its action upon the child is constant and long +sustained. Hence, it is not surprising that the growth of his +character and powers is +<span class="pagenum">Page 183<a name="Page_183" id="Page_183"></a></span> +commonly unequal. At one point we may find a +good crop of virtues, at another a barren tract; and the home +influences which have ripened the one and blighted the other are +calculated by the lapse of time to increase the contrast rather than +to diminish it.</p> + +<p>I suppose it is for this reason that the custom of sending children to +boarding-schools has so firm a hold among us. The boarding-school +forms an environment selected to correct the inequalities which result +from the special action upon the child of individual homes. The life +of a boy in one of our large public schools is well calculated to act +as a corrective in this way not only by reason of its ordered routine +and discipline, but still more because it is affected, perhaps for the +first time, by the strong force of public opinion. It is the strength +of this public opinion which gives to our public schools their +peculiar character and produces their peculiar effects. That which the +schoolboy most despises is what he calls "Bad Form," and he bows down +and worships an idol he himself has set up, the name of which is "Good +Form." Public opinion forms the code of morals observed in the school. +The standard set is commonly not so high as to be very difficult of +attainment. It demands many good qualities. To lie, to sneak, to tell +tales, to bully, to "put on side," are bad form. In some respects the +definition of what is virtuous may be a little hazy. Thus it may be +wrong to cheat to gain a prize, but to copy from one's neighbour only +so much as will enable one to pass muster and escape condemnation +<span class="pagenum">Page 184<a name="Page_184" id="Page_184"></a></span> +is no great sin. In short, good form demands that a boy should have all +the social virtues: that he should be a good fellow, easy to live +with, and possessed of a high sense of public spirit—good qualities +certainly, though perhaps not those which help to make the reformers +or martyrs of this world.</p> + +<p>The school life is the life of the herd, and to be successful in it +the boy must mingle with the herd, not break from it or shun it. Good +form—if we came to analyse the conception that underlies it—consists +only in a close approximation to the standard pattern; bad form, in +any deviation from it. It is this similarity of type and community of +ideals which makes it so easy for most public-school boys to get on +well with one another. When in after life they are thrown among a set +of men who know nothing of their conception of good form, and whose +training has been on completely different lines, there may be a +corresponding difficulty.</p> + +<p>Now what is true of public-school life is of course also true of the +larger life after schooldays are over for which all education is a +preparation. These qualities of sociability and good sportsmanship +will stand a man in good stead throughout life. Even the most ardent +and active spirit will benefit by being subjected for some years to +this steady pressure of public opinion. The most part will learn from +it good sense, consideration for others, and self-control. As they +pass from the lower forms to the higher in the school they will learn +too to support authority without doing injustice, and to bring the +<span class="pagenum">Page 185<a name="Page_185" id="Page_185"></a></span> +weight of public opinion to bear upon others. And to all this +training many a man owes his happiness in after life—a happiness +which he could not have secured if his character had been moulded only +by the environment of his home, or by the home in combination with the +less-powerful corrective of a day school. For the nervous child the +passage from home to school life may involve considerable mental +strain. He may be morbidly self-conscious and timid, or, unknown to +himself—because he has as yet no power of self-analysis and has no +opportunities of comparing himself with others—he may have developed +certain eccentricities. In most cases the plunge into school life will +be taken well enough; in a few the little vessel will not right +itself, and proves permanently unseaworthy. No doubt as a rule a +private school will have preceded the public school, and this +gradation should make the entrance to the public school a lesser +ordeal. But it often happens that it is just in the case of the +nervous child that this intermediate stage has been omitted, and that +his thirteenth birthday finds him still in the home circle.</p> + +<p>If the boy's father has first-hand knowledge of life in the lower +forms of public schools, his experience may enable him to form some +estimate of the effect of school life upon the nervous system of his +son. It is when parents or guardians have no such experience of their +own to guide them that mistakes are most liable to be made. I can +myself remember the unhappy state of some solitary and eccentric +schoolfellows of mine who aroused the +<span class="pagenum">Page 186<a name="Page_186" id="Page_186"></a></span> +resentment of "the Herd" by +their behaviour or opinions. If it is clear that the boy has a +peculiar temperament and is likely to suffer in this way, some <i>via +media</i> must be found. The home has failed so that he must leave home +and come under the influence of some one who understands the nature of +the difficulty and can adapt the boy to school life. A change of +environment of this sort as a preliminary to the public school is +often all that is needed. If his age permits, every effort should be +made in this way to obtain for the nervous child who has developed +peculiarities or faults the benefits of a public-school education.</p> + +<p>Some types of nervous children will show immediate improvement when +they go to school. The boy who is passionate and disobedient, and +whose parents cannot control him, is best at school. Boys who, from +being much with grown-up people, have become too precocious and have +acquired the habits and tastes of their elders, will dislike school at +first, but it will do them good. Their fault shows that they are quick +to learn and sensitive to the influences of others, and they will soon +adapt themselves to their new surroundings. Boys who are dreamy and +imaginative, who early adopt a "specialist" attitude towards life, +who, however ignorant they may be of everything else, cultivate a +reputation for omniscience in some particular subject, such as +Egyptology, astronomy, or the construction of battleships, are usually +nervous boys whose symptoms will disappear at school. Where undue +timidity, phobia, or habit spasm is +<span class="pagenum">Page 187<a name="Page_187" id="Page_187"></a></span> +present, the question is more +difficult to decide. Every individual case must be studied as a whole, +and our object should be not unnecessarily to deprive the boy of the +wholesome training of public-school life.</p> + +<p>There are parents who from sheer ignorance add to the difficulties +which the boy encounters in going to school. Failure to appreciate +very small points may cause unnecessary suffering. To be the only boy +in the school to wear combinations is not a distinction that any new +boy craves, however strong his nerves may be. A friend of mine still +relates with feeling how, twenty years ago, he arrived at school with +shirts which <i>buttoned</i> at the neck! At night when every one else in +the dormitory was asleep he sat for hours on his bed, miserable beyond +words, removing the buttons and doing his best in the dark to bore +buttonholes which would admit what every other boy in the school +had—a collar stud.</p> + +<p>With girls perhaps this question of fitness for school life does not +arise in so urgent a way. Girls are usually older when they go to +school, and girls' schools are perhaps less terrifying and more like +home. There is, however, one important point which should be borne in +mind. The date of the onset of puberty varies much in both sexes. If +the boy grows to a great hulking fellow at fourteen, and even displays +a desire secretly to borrow his father's razor, he is at no particular +disadvantage as compared with his fellows. He is so much bigger and +stronger than the others that he may +<span class="pagenum">Page 188<a name="Page_188" id="Page_188"></a></span> +thereby early enjoy the +distinction of playing at "big side," or of getting a place in the +school Eleven. He is probably much envied by those of the same age +who, with the aid of their youthful aspect, can still occasionally +extract compensation by inducing the railway company to let them +travel to school at half fare. But with girls it is different. Many at +fourteen or fifteen are children still; some are grown up, with the +tastes, feelings, and attraction of maturity. Those who have developed +fastest are often, for that very reason, kept backward in school +learning. Often they are nervously the least stable. Now that large +schools for girls on the model of our public schools are become the +fashion, such precociously developed and nervously unstable girls are +apt to find themselves in the very uncongenial society of little girls +of twelve or thirteen. The elder girls commonly hold aloof, while +mistresses are apt to view this precocious development with +disapproval, and to attempt to retard what cannot be retarded by +insisting that the young woman has remained a child. I remember being +called in consultation by a surgeon who had been asked to operate for +appendicitis upon a girl of fourteen. I found a tall, well-grown girl, +with an appearance and manner that made her look four years older. I +could find no signs of appendicitis, but I learned from her that she +had been for three months at a large girls' school, and that in a few +days' time her second term was due to begin. As we became friends, she +agreed that her appendicitis and her resolve not +<span class="pagenum">Page 189<a name="Page_189" id="Page_189"></a></span> +to return to school, +where she was unhappy, were but different ways of saying the same +thing. She was an only child who had travelled a great deal with her +parents, had found her interests in their pursuits, and had grown +backward in school work. The little girls with whom she was expected +to associate seemed to her mere children. The elder girls did not want +her friendship, and snubbed her. I prescribed a change to a small +boarding-school with only a few girls, where age differences would not +matter so much, and where she could make friends with girls older than +herself, though not more mature.</p> + +<p>Into their school life we need not follow the children. Happily the +time is past when schoolmasters and schoolmistresses were incapable of +understanding their charges, and confounded nervous exhaustion with +stupidity or timidity with incapacity.</p> + +<p>And so we come back to the point from which we started:</p> + +<p>The nervous infant, restless, wriggling, and constantly crying! The +nervous child, unstable, suggestible, passionate, and full of nameless +fears! The nervous schoolboy or schoolgirl prone to self-analysis, +subject-conscious, and easily exhausted! And how many and how various +are the manifestations of this temperament! Refusal of food, refusal +of sleep, negativism, irritability, and violent fits of temper, +vomiting, diarrhœa, morbid flushing and blushing, habit spasms, +phobias—all controlled not by reproof or by +<span class="pagenum">Page 190<a name="Page_190" id="Page_190"></a></span> +medicine, but by good management and a clear understanding of their nature.</p> + +<p>The hygiene of the child's mind is as important as the hygiene of his +body, and both are studies proper for the doctor. Neuropathy and an +unsound, nervous organisation are often enough legacies from the +nervous disorders of childhood.</p> +<p> </p> +<p> </p> + +<p><span class="pagenum">Page 191<a name="Page_191" id="Page_191"></a></span></p> +<h3>INDEX</h3> +<p> </p> + +<p>Abdomen, prominent, <a href="#Page_151">151</a><br /> +<br /> +Abdominal symptoms of neurosis, <a href="#Page_153">153</a><br /> +<br /> +Accent, local, facility with which acquired, <a href="#Page_17">17</a><br /> +<br /> +Acetone, in breath and urine during cyclic vomiting, <a href="#Page_86">86</a><br /> +<br /> +Acidosis, accompanying cyclic vomiting, <a href="#Page_85">85</a><br /> +<br /> +Action, imitativeness of, <a href="#Page_19">19</a><br /> +<span class="in1">liberty of, in early childhood, <a href="#Page_22">22</a></span><br /> +<br /> +Activities in the nursery, <a href="#Page_98">98</a><br /> +<span class="in1">not to be restrained, <a href="#Page_23">23</a>, <a href="#Page_24">24</a>, +<a href="#Page_98">98</a></span><br /> +<span class="in1">without intervention of grown-up people, <a href="#Page_99">99</a></span><br /> +<span class="in1">wonderful nature of, <a href="#Page_24">24</a></span><br /> +<br /> +Adenoid vegetations, night-terrors aggravated by, <a href="#Page_136">136</a><br /> +<span class="in1">removal of, in treatment of enuresis, <a href="#Page_93">93</a></span><br /> +<br /> +Adolescence, and education on sexual matters, <a href="#Page_169">169</a>, <a href="#Page_175">175</a><br /> +<br /> +Adults, child in relation to the society of, <a href="#Page_36">36</a>, <a href="#Page_38">38</a><br /> +<br /> +Æsthetic sense, in early childhood, <a href="#Page_48">48</a><br /> +<br /> +Affection, in the child, <a href="#Page_48">48</a><br /> +<br /> +Air hunger, in cyclic vomiting, <a href="#Page_86">86</a><br /> +<br /> +Air swallowing, habitual action of, <a href="#Page_79">79</a><br /> +<br /> +Albuminuria, associated with faulty posture, <a href="#Page_152">152</a><br /> +<span class="in1">cause of, in neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Allimentary disturbances, symptom of, <a href="#Page_157">157</a><br /> +<br /> +Alkali, in treatment of cyclic vomiting, <a href="#Page_87">87</a><br /> +<br /> +Anæmia, of neuropaths, <a href="#Page_152">152</a><br /> +<br /> +Anorexia nervosa, <a href="#Page_50">50</a><br /> +<span class="in1">A case illustrating, <a href="#Page_50">50</a></span><br /> +<br /> +Apnœa, fatal cases of, <a href="#Page_83">83</a><br /> +<span class="in1">following burst of crying, <a href="#Page_82">82</a></span><br /> +<span class="in1">twitching of facial muscles in, <a href="#Page_83">83</a></span><br /> +<br /> +Appetite, emotional states affecting, <a href="#Page_52">52</a><br /> +<span class="in1">loss of, <a href="#Page_51">51</a></span><br /> +<span class="in2">case illustrating, <a href="#Page_51">51</a></span><br /> +<span class="in2">causes and characteristics, <a href="#Page_56">56</a>, <a href="#Page_62">62</a></span><br /> +<span class="in2">treatment, <a href="#Page_62">62</a></span><br /> +<span class="in1">means of stimulating, <a href="#Page_53">53</a></span><br /> +<span class="in1">nature of the sensation of, <a href="#Page_52">52</a></span><br /> +<br /> +Apprehension, causes of, <a href="#Page_28">28</a><br /> +<span class="in1">growth of neuroses in atmosphere of, <a href="#Page_75">75</a></span><br /> +<br /> +Artificial feeding, <a href="#Page_109">109</a>, <a href="#Page_113">113</a><br /> +<br /> +Aspirin, <a href="#Page_71">71</a><br /> +<br /> +Asthma, treatment of, <a href="#Page_166">166</a><br /> +<br /> +Attention, child's love of attracting, <a href="#Page_32">32</a>, <a href="#Page_35">35</a>, <a href="#Page_59">59</a><br /> +<span class="in1">examples of, <a href="#Page_33">33</a>, <a href="#Page_39">39</a></span><br /> +<br /> +Authority, delight in defying, <a href="#Page_43">43</a>-46<br /> +<span class="in1">over-exercise of, by parents, results of, <a href="#Page_42">42</a>, +<a href="#Page_43">43</a>, <a href="#Page_45">45</a></span><br /> + <br /></p> + +<p>Babies. <i>See</i> Newborn Baby<br /> +<br /> +Backward development, <a href="#Page_56">56</a>, <a href="#Page_146">146</a><br /> +<span class="in1">signs of, <a href="#Page_56">56</a></span><br /> +<br /> +"Bad form," <a href="#Page_183">183</a><br /> +<br /> +Bad habits, <a href="#Page_77">77</a>-80<br /> +<br /> +Bath, baby's first experience of, <a href="#Page_105">105</a>, <a href="#Page_106">106</a><br /> +<br /> +Bed, dislike of, <a href="#Page_28">28</a><br /> +<span class="in1">how overcome, <a href="#Page_28">28</a>, <a href="#Page_29">29</a></span><br /> +<span class="in1">efforts to resist preparation for, <a href="#Page_64">64</a>, +<a href="#Page_65">65</a>, <a href="#Page_66">66</a></span><br /> +<br /> +Bedroom, airing and temperature of, <a href="#Page_69">69</a><br /> +<br /> +Bedtime, <a href="#Page_64">64</a>, <a href="#Page_66">66</a><br /> +<span class="in1">management at, <a href="#Page_65">65</a>, <a href="#Page_66">66</a></span><br /> +<br /> +Bed wetting. <i>See</i> Enuresis<br /> + +<span class="pagenum">Page 192<a name="Page_192" id="Page_192"></a></span> + +<br /> +Behaviour. <i>See</i> Conduct<br /> +<br /> +Bladder, hydrostatic distension of, for enuresis, <a href="#Page_92">92</a>, <a href="#Page_93">93</a><br /> +<br /> +Boarding-schools, object of, <a href="#Page_183">183</a><br /> +<br /> +Bodily ailments, and instability of nervous control, connection<br /> +<span class="in1">between, <a href="#Page_120">120</a></span><br /> +<span class="in1"><i>See also</i> Disorders</span><br /> +<br /> +Body,<br /> +<span class="in1">and mind, development of, <a href="#Page_120">120</a>, <a href="#Page_121">121</a></span><br /> +<span class="in1">development of, <a href="#Page_146">146</a></span><br /> +<span class="in2">environment influencing, <a href="#Page_5">5</a></span><br /> +<span class="in1">effect of mind on, <a href="#Page_51">51</a></span><br /> +<span class="in1">gradual alterations in the shape of, <a href="#Page_146">146</a></span><br /> +<span class="in1">infantile characteristics in later childhood, <a href="#Page_145">145</a>, +<a href="#Page_146">146</a></span><br /> +<br /> +Bone, and muscle, changes in, in infantile children, <a href="#Page_148">148</a><br /> +<br /> +Books,<br /> +<span class="in1">child's attitude towards, <a href="#Page_99">99</a></span><br /> +<span class="in1">educative value of, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<span class="in1">kinds most suitable, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<br /> +Brachial nerve, pressure causing tetany, <a href="#Page_81">81</a><br /> +<br /> +Breast-feeding,<br /> +<span class="in1">best time for, <a href="#Page_109">109</a></span><br /> +<span class="in1">causes of failure in, <a href="#Page_108">108</a></span><br /> +<span class="in1">observations on, <a href="#Page_106">106</a></span><br /> +<span class="in1"><i>See also</i> Lactation</span><br /> +<br /> +Breath-holding, <a href="#Page_81">81</a>, <a href="#Page_82">82</a><br /> +<span class="in1">action during, <a href="#Page_84">84</a></span><br /> +<span class="in1">fatal cases of, <a href="#Page_83">83</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_82">82</a></span><br /> +<br /> +Bromides, administration of, <a href="#Page_71">71</a><br /> +<span class="in1">to newborn baby, <a href="#Page_110">110</a>, <a href="#Page_111">111</a></span><br /> + <br /></p> + +<p>Cajoling, futility of, <a href="#Page_26">26</a><br /> +<br /> +Calcium bromide, in treatment of spasms, <a href="#Page_84">84</a><br /> +<br /> +Calcium metabolism, disturbance of, <a href="#Page_82">82</a><br /> +<br /> +Care, ill effects of excess of, <a href="#Page_163">163</a><br /> +<br /> +Carpo-pedal spasm, <a href="#Page_81">81</a><br /> +<br /> +Catarrhal infections, <a href="#Page_155">155</a><br /> +<span class="in1">connection of rheumatism with, <a href="#Page_155">155</a></span><br /> +<br /> +Cerebral anæmia, <a href="#Page_140">140</a><br /> +<br /> +Cerebral circulation, stagnation of, <a href="#Page_140">140</a><br /> +<br /> +Cerebral exhaustion. <i>See</i> Mental Exhaustion<br /> +<br /> +Cerebral functions,<br /> +<span class="in1">rapid growth of, <a href="#Page_5">5</a></span><br /> +<span class="in1">unstable in the child, <a href="#Page_6">6</a></span><br /> +<span class="in1"><i>See also</i> Mental</span><br /> +<br /> +Character,<br /> +<span class="in1">formation of, <a href="#Page_126">126</a></span><br /> +<span class="in1">during school life, <a href="#Page_184">184</a>, <a href="#Page_186">186</a></span><br /> +<span class="in1">home influence in the development of, <a href="#Page_182">182</a>, +<a href="#Page_185">185</a>, <a href="#Page_186">186</a></span><br /> +<span class="in1">ideals of, how inculcated, <a href="#Page_125">125</a></span><br /> +<br /> +Children's parties, disadvantages of, <a href="#Page_102">102</a><br /> +<br /> +Chloral, administration of, <a href="#Page_71">71</a><br /> +<span class="in2">to newborn baby, <a href="#Page_110">110</a>, <a href="#Page_111">111</a></span><br /> +<span class="in1">in treatment of spasms, <a href="#Page_84">84</a></span><br /> +<br /> +Chorea, <a href="#Page_155">155</a><br /> +<span class="in1">and rheumatism, association between, <a href="#Page_155">155</a></span><br /> +<span class="in1">symptom of cerebral irritability, <a href="#Page_156">156</a></span><br /> +<span class="in1">treatment of, <a href="#Page_156">156</a></span><br /> +<br /> +Chvostek's sign, characteristics and nature of, <a href="#Page_81">81</a><br /> +<br /> +Circulation, cerebral,<br /> +<span class="in1">stagnation of, <a href="#Page_140">140</a></span><br /> +<span class="in1">nervous control of, <a href="#Page_140">140</a></span><br /> +<br /> +Claustrophobia, <a href="#Page_180">180</a><br /> +<br /> +Clothing,<br /> +<span class="in1">kind suitable, <a href="#Page_69">69</a></span><br /> +<span class="in1">new, child's delight in, <a href="#Page_48">48</a></span><br /> +<br /> +Coaxing, <a href="#Page_67">67</a><br /> +<span class="in1">futility of, 26</span><br /> +<br /> +Cold douches, improving vasomotor tone, <a href="#Page_154">154</a><br /> +<br /> +Coldness of extremities, <a href="#Page_141">141</a><br /> +<br /> +Conduct,<br /> +<span class="in1">control of, factors in, <a href="#Page_33">33</a>, <a href="#Page_129">129</a></span><br /> +<span class="in1">errors of, and sexual instincts, <a href="#Page_176">176</a></span><br /> +<span class="in2">control of, <a href="#Page_39">39</a></span><br /> +<span class="in2">correction of, <a href="#Page_127">127</a></span><br /> +<span class="in2">due to faults of management, <a href="#Page_127">127</a></span><br /> +<span class="in2">in neuropathic children, <a href="#Page_126">126</a></span><br /> +<span class="in1">excessive introspection influencing, <a href="#Page_139">139</a></span><br /> +<span class="in1">ideals of, how inculcated, <a href="#Page_125">125</a></span><br /> +<span class="in1">influence of environment on, <a href="#Page_131">131</a></span><br /> +<span class="in1">influenced by suggestion, <a href="#Page_13">13</a></span><br /> +<span class="in1">mother's influence on, <a href="#Page_11">11</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">perverse, <a href="#Page_45">45</a></span><br /> +<span class="in1">suggestion in the control of, <a href="#Page_130">130</a></span><br /> + +<span class="pagenum">Page 193<a name="Page_193" id="Page_193"></a></span> + +<br /> +Constipation, <a href="#Page_12">12</a><br /> +<span class="in1">mental causes of, <a href="#Page_30">30</a>, <a href="#Page_80">80</a></span><br /> +<span class="in1">negativism in, <a href="#Page_80">80</a></span><br /> +<span class="in1">perversion of suggestion a common cause of, <a href="#Page_30">30</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_80">80</a></span><br /> +<br /> +Constitution, delicacy of, <a href="#Page_161">161</a><br /> +<br /> +Convulsions, fatal cases of, <a href="#Page_83">83</a><br /> +<span class="in1">generalised, <a href="#Page_81">81</a></span><br /> +<br /> +Convulsive disorders, <a href="#Page_149">149</a>, <a href="#Page_150">150</a><br /> +<br /> +Cough, nervous, <a href="#Page_73">73</a><br /> +<br /> +Counter-opposition, child's opposition growing with, <a href="#Page_60">60</a>, <a href="#Page_67">67</a>, +<a href="#Page_179">179</a><br /> +<br /> +Crying, constant, <a href="#Page_54">54</a>, <a href="#Page_67">67</a><br /> +<span class="in1">formation of habit of, <a href="#Page_115">115</a></span><br /> +<span class="in1">in emotional and excitable children, <a href="#Page_82">82</a></span><br /> +<span class="in1">management of, <a href="#Page_68">68</a></span><br /> +<span class="in1">mechanism of, <a href="#Page_149">149</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_67">67</a></span><br /> +<span class="in1">purposeful, <a href="#Page_68">68</a></span><br /> +<br /> +Cyclic or periodic vomiting. <i>See</i> Vomiting<br /> + <br /></p> + +<p>Day-dreams, indicating nervous temperament, <a href="#Page_137">137</a><br /> +<br /> +Deceit, <a href="#Page_123">123</a>, <a href="#Page_124">124</a><br /> +<br /> +Defæcation, inhibition of, <a href="#Page_11">11</a>, <a href="#Page_12">12</a>, <a href="#Page_13">13</a><br /> +<span class="in1">painful, <a href="#Page_2">2</a></span><br /> +<br /> +Delicacy of constitution, <a href="#Page_161">161</a><br /> +<br /> +Delirium, tendency to, <a href="#Page_161">161</a>, <a href="#Page_162">162</a><br /> +<br /> +Depolarisation of ideas, <a href="#Page_172">172</a><br /> +<br /> +Depression, recurrence of periods of, <a href="#Page_61">61</a><br /> +<br /> +Dexterity, lack of, <a href="#Page_56">56</a><br /> +<span class="in1">manual, advantages of, <a href="#Page_122">122</a></span><br /> +<span class="in1">toys developing, <a href="#Page_96">96</a></span><br /> +<br /> +Diaphragm, spasm of, <a href="#Page_82">82</a><br /> +<br /> +Diarrhoea, mucous, <a href="#Page_142">142</a><br /> +<br /> +Diet, likes and dislikes for articles of, <a href="#Page_25">25</a><br /> +<span class="in1">opposition to, <a href="#Page_25">25</a></span><br /> +<span class="in1">of newborn child, changes in, <a href="#Page_113">113</a></span><br /> +<span class="in1"><i>See also</i> Food</span><br /> +<br /> +Digestion, emotional states affecting, <a href="#Page_52">52</a>, <a href="#Page_53">53</a><br /> +<br /> +Digestive disorders, mental causes of, <a href="#Page_51">51</a>, <a href="#Page_52">52</a>, <a href="#Page_62">62</a><br /> +<br /> +Digestive neuroses, <a href="#Page_50">50</a><br /> +<br /> +Digestive system, symptoms of extreme sensibility of, <a href="#Page_141">141</a><br /> +<br /> +Dirt eating, <a href="#Page_80">80</a><br /> +<br /> +Discipline, <a href="#Page_43">43</a><br /> +<span class="in1">in later childhood, <a href="#Page_118">118</a></span><br /> +<span class="in1">in the school, <a href="#Page_183">183</a></span><br /> +<span class="in1">misdirected efforts at enforcing, <a href="#Page_44">44</a></span><br /> +<span class="in1">severe, effects of, <a href="#Page_119">119</a></span><br /> +<br /> +Dishonesty, <a href="#Page_127">127</a><br /> +<br /> +Disobedience, <a href="#Page_43">43</a>, <a href="#Page_45">45</a><br /> +<span class="in1">growth of, <a href="#Page_42">42</a></span><br /> +<span class="in1">habit of, <a href="#Page_59">59</a></span><br /> +<span class="in1">personality and, <a href="#Page_58">58</a></span><br /> +<span class="in1">perverse attitude of, <a href="#Page_34">34</a></span><br /> +<span class="in1">reproof and coaxing causing, <a href="#Page_61">61</a></span><br /> +<br /> +Disorders, ætiology of, <a href="#Page_14">14</a><br /> +<span class="in1">associated with neurosis, <a href="#Page_145">145</a></span><br /> +<span class="in1">common, <a href="#Page_140">140</a>-141</span><br /> +<span class="in1">environment as cause and cure of, <a href="#Page_142">142</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_145">145</a>-159</span><br /> +<span class="in1">treatment of, <a href="#Page_142">142</a></span><br /> +<span class="in1">trifling, <a href="#Page_162">162</a></span><br /> +<br /> +Diuresis, excessive, <a href="#Page_141">141</a><br /> +<br /> +Doll, child's care of, an example of imitativeness, <a href="#Page_23">23</a><br /> +<span class="in1">educative value of, <a href="#Page_98">98</a></span><br /> +<br /> +Douches, cold, improving vasomotor tone, <a href="#Page_154">154</a><br /> +<br /> +Dover's powder, <a href="#Page_72">72</a><br /> +<br /> +Dreams, <a href="#Page_70">70</a><br /> +<span class="in1">nature of, indicating nature of mental unrest, <a href="#Page_137">137</a></span><br /> +<br /> +Drugs, in sleeplessness, <a href="#Page_70">70</a>, <a href="#Page_71">71</a><br /> +<br /> +Ductless glands, in relation to infantile characteristics, <a href="#Page_147">147</a><br /> +<br /> +Dullards, <a href="#Page_149">149</a><br /> +<br /> +Dyspepsia, complications of, <a href="#Page_54">54</a><br /> +<span class="in1">course and effects of, <a href="#Page_54">54</a></span><br /> +<span class="in1">mental aspects of, <a href="#Page_53">53</a></span><br /> +<span class="in1">nervous symptoms of, <a href="#Page_53">53</a>, <a href="#Page_54">54</a></span><br /> +<span class="in1">symptoms in newborn infant, <a href="#Page_116">116</a></span><br /> +<span class="in1">treatment, <a href="#Page_63">63</a></span><br /> + <br /></p> + + +<p>Early childhood, care during, <a href="#Page_105">105</a><br /> +<span class="in1">impulse of opposition in, <a href="#Page_35">35</a></span><br /> +<span class="in1">love of power in, <a href="#Page_32">32</a>, <a href="#Page_36">36</a></span><br /> + +<span class="pagenum">Page 194<a name="Page_194" id="Page_194"></a></span> + +<br /> +Early childhood, nervousness in, <a href="#Page_104">104</a><br /> +<span class="in1">reasoning power in, <a href="#Page_40">40</a></span><br /> +<span class="in1">three common neuroses of, <a href="#Page_74">74</a></span><br /> +<span class="in1">toys, books, and amusements in, <a href="#Page_96">96</a></span><br /> +<span class="in1"><i>See also</i> Newborn Baby</span><br /> +<br /> +Education, aim of, <a href="#Page_118">118</a>-120<br /> +<span class="in1">by games and toys, <a href="#Page_96">96</a></span><br /> +<span class="in1">on sexual matters, <a href="#Page_169">169</a></span><br /> +<br /> +Educative value, of books, games, and toys, <a href="#Page_98">98</a>-100<br /> +<br /> +Emotional states, appetite affected by, <a href="#Page_52">52</a><br /> +<span class="in1">causing spasm, <a href="#Page_83">83</a></span><br /> +<span class="in1">management of, <a href="#Page_82">82</a></span><br /> +<span class="in1">of neurotics, exaggeration of, <a href="#Page_131">131</a></span><br /> +<span class="in1">physical disturbances due to, <a href="#Page_53">53</a>, <a href="#Page_54">54</a></span><br /> +<span class="in1">producing laryngismus stridulus, <a href="#Page_82">82</a></span><br /> +<br /> +Emotional storms, <a href="#Page_68">68</a><br /> +<br /> +Endocrine glands, <a href="#Page_147">147</a><br /> +<br /> +Enuresis, <a href="#Page_81">81</a>, <a href="#Page_89">89</a><br /> +<span class="in1">causal factors in, <a href="#Page_89">89</a>, <a href="#Page_90">90</a></span><br /> +<span class="in1">characteristics and peculiarities of, <a href="#Page_90">90</a>-92</span><br /> +<span class="in1">condition of urine during, <a href="#Page_93">93</a></span><br /> +<span class="in1">mental aspects of, <a href="#Page_95">95</a></span><br /> +<span class="in1">mistakes in treatment of, <a href="#Page_94">94</a></span><br /> +<span class="in1">perversion of suggestion as cause of, <a href="#Page_89">89</a></span><br /> +<span class="in1">removal of tonsils in, <a href="#Page_92">92</a>, <a href="#Page_93">93</a></span><br /> +<span class="in1">treatment, essentials in, <a href="#Page_94">94</a></span><br /> +<span class="in2">hypnotic suggestion in, <a href="#Page_95">95</a></span><br /> +<span class="in2">methods of, <a href="#Page_92">92</a>-93</span><br /> +<br /> +Environment, body moulded and shaped by, <a href="#Page_5">5</a><br /> +<span class="in1">change of, beneficial effects of, <a href="#Page_13">13</a></span><br /> +<span class="in1">effect in developing child's powers, <a href="#Page_22">22</a></span><br /> +<span class="in1">effect on common disorders, <a href="#Page_142">142</a></span><br /> +<span class="in1">errors of, and neuropathic children, <a href="#Page_126">126</a></span><br /> +<span class="in1">essentials of, <a href="#Page_39">39</a></span><br /> +<span class="in1">faulty contact with, in neuropathic children, <a href="#Page_138">138</a></span><br /> +<span class="in1">for neuropaths, <a href="#Page_132">132</a></span><br /> +<span class="in1">influence on conduct in later childhood, <a href="#Page_131">131</a></span><br /> +<span class="in1">influence on mental processes, <a href="#Page_10">10</a></span><br /> +<span class="in1">influence on personality, <a href="#Page_24">24</a>, <a href="#Page_25">25</a></span><br /> +<span class="in1">irritating nature of the adult mind in, <a href="#Page_36">36</a>, <a href="#Page_38">38</a></span><br /> +<span class="in1">of the home, reflected in the child, <a href="#Page_182">182</a></span><br /> +<span class="in1">of school life, <a href="#Page_183">183</a>-186</span><br /> +<span class="in1">stimulus of, <a href="#Page_22">22</a></span><br /> +<span class="in1">susceptibility to influences of, <a href="#Page_25">25</a>, <a href="#Page_31">31</a></span><br /> +<br /> +Epilepsy, cyclical character of, <a href="#Page_61">61</a><br /> +<br /> +Evil, inborn disposition to, <a href="#Page_130">130</a><br /> +<br /> +Excitable children, management of, <a href="#Page_82">82</a><br /> +<br /> +Exercise, sleep in relation to, <a href="#Page_69">69</a><br /> +<br /> +Exhaustion. <i>See</i> Mental Exhaustion<br /> +<br /> +Expostulation, frequent, bad effects of, <a href="#Page_124">124</a>, <a href="#Page_125">125</a><br /> +<span class="in1"><i>See also</i> Reproof</span><br /> +<br /> +Expressions, to attract attention, <a href="#Page_39">39</a><br /> + <br /> +</p> + + +<p>Facial muscles, twitching of, <a href="#Page_81">81</a><br /> +<span class="in1">associated with apnœa, <a href="#Page_83">83</a></span><br /> +<br /> +Fæces, incontinence of, <a href="#Page_92">92</a><br /> +<br /> +Fainting fits, <a href="#Page_140">140</a><br /> +<span class="in1">cause and characteristics, <a href="#Page_140">140</a></span><br /> +<span class="in1">control of, <a href="#Page_141">141</a></span><br /> +<span class="in1">of neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Fatigue, mental, physical, and visceral, <a href="#Page_143">143</a><br /> +<br /> +Fats, lowered tolerance to, <a href="#Page_87">87</a><br /> +<br /> +Faults, correction of, <a href="#Page_127">127</a><br /> +<span class="in1">not corrected by too frequent reproof, <a href="#Page_124">124</a>, <a href="#Page_125">125</a></span><br /> +<br /> +Fear, <a href="#Page_39">39</a><br /> +<span class="in1">causes of, <a href="#Page_28">28</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_134">134</a>, <a href="#Page_135">135</a></span><br /> +<span class="in1">prominent psychical symptom of neuropathic children, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">treatment of, <a href="#Page_135">135</a></span><br /> +<br /> +Feeding, <a href="#Page_55">55</a><br /> +<span class="in1">artificial, <a href="#Page_109">109</a>, <a href="#Page_113">113</a></span><br /> +<span class="in1">factors in, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in1">of newborn infant, regularity in, <a href="#Page_116">116</a></span><br /> +<br /> +Fertilisation, method of imparting knowledge of, <a href="#Page_174">174</a><br /> + +<span class="pagenum">Page 195<a name="Page_195" id="Page_195"></a></span> + +<br /> +Food, force of suggestion in relation to, <a href="#Page_25">25</a>-27<br /> +<span class="in1">healthy desire for, <a href="#Page_62">62</a></span><br /> +<span class="in1">likes and dislikes for, <a href="#Page_25">25</a></span><br /> +<span class="in2">how overcome, <a href="#Page_26">26</a></span><br /> +<span class="in1">phenomena of the desire of, <a href="#Page_52">52</a></span><br /> +<span class="in1">refusal of, <a href="#Page_35">35</a>, <a href="#Page_50">50</a></span><br /> +<span class="in2">nervous causes of, <a href="#Page_52">52</a></span><br /> +<span class="in2">persistent, factors encouraging, <a href="#Page_57">57</a></span><br /> +<span class="in2">suggestion in relation to, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in2">treatment of, <a href="#Page_26">26</a>, <a href="#Page_55">55</a>, <a href="#Page_62">62</a></span><br /> +<br /> +Force and cajoling, futility of, <a href="#Page_26">26</a><br /> +<br /> +Freud, teaching of, <a href="#Page_176">176</a><br /> +<br /> +Functional disturbances, in combination with organic disease, <a href="#Page_4">4</a><br /> + <br /> +</p> + +<p>Gait, peculiarity of, <a href="#Page_74">74</a><br /> +<br /> +Games, educative value of, <a href="#Page_96">96</a>, <a href="#Page_98">98</a><br /> +<br /> +Gastric disturbances, <a href="#Page_54">54</a><br /> +<br /> +Gastric juice, psychic secretion of, <a href="#Page_52">52</a><br /> +<br /> +Gastric symptoms, of neurosis, <a href="#Page_153">153</a><br /> +<br /> +Gastro-intestinal derangement, causes of, <a href="#Page_141">141</a><br /> +<span class="in1">environment as cause and cure of, <a href="#Page_142">142</a></span><br /> +<br /> +Gentleness, <a href="#Page_119">119</a><br /> +<span class="in1">inculcation of, <a href="#Page_129">129</a></span><br /> +<br /> +Girls' schools, <a href="#Page_188">188</a><br /> +<br /> +Glottis, spasm of, strong emotion causing, <a href="#Page_82">82</a><br /> +<br /> +"Good form," <a href="#Page_183">183</a>, <a href="#Page_184">184</a><br /> +<br /> +Grasping habit, reproof in relation to, <a href="#Page_21">21</a><br /> +<br /> +Growing pains, <a href="#Page_167">167</a><br /> + <br /> +</p> + +<p>Habit spasms, age of appearance of, <a href="#Page_74">74</a><br /> +<span class="in1">cause of, <a href="#Page_74">74</a></span><br /> +<span class="in1">definition of, <a href="#Page_73">73</a></span><br /> +<span class="in1">examples of, <a href="#Page_73">73</a></span><br /> +<span class="in1">spread of, <a href="#Page_75">75</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_74">74</a></span><br /> +<span class="in1">treatment of, <a href="#Page_76">76</a></span><br /> +<br /> +Habits, regulation of, <a href="#Page_30">30</a><br /> +<span class="in1">suggestion in relation to, <a href="#Page_30">30</a></span><br /> +<br /> +Habitual actions, infant's pleasure in, <a href="#Page_77">77</a><br /> +<span class="in1">mental unrest in relation to, <a href="#Page_77">77</a></span><br /> +<span class="in1">of the parent, reproduction in the child, <a href="#Page_75">75</a></span><br /> +<span class="in1">varieties and characteristics, <a href="#Page_77">77</a></span><br /> +<br /> +Habitual wakefulness, <a href="#Page_70">70</a><br /> +<br /> +Hands, control of movement of, <a href="#Page_19">19</a>, <a href="#Page_22">22</a><br /> +<span class="in1">expressionless, <a href="#Page_56">56</a></span><br /> +<br /> +Happiness and contentment, of child when playing alone, <a href="#Page_96">96</a><br /> +<br /> +Headache, periodic. <i>See</i> Migraine<br /> +<br /> +Heat and cold, newborn baby in relation to, <a href="#Page_106">106</a><br /> +<br /> +Heat and flushing, sudden sensations of, <a href="#Page_141">141</a><br /> +<br /> +Heredity, and temperament, <a href="#Page_10">10</a><br /> +<span class="in1">and type of child, <a href="#Page_31">31</a></span><br /> +<span class="in1">nervous disorders in relation to, <a href="#Page_5">5</a></span><br /> +<br /> +Home influence, in development of character, <a href="#Page_182">182</a>, <a href="#Page_185">185</a>, <a href="#Page_186">186</a><br /> +<span class="in1">reflected in the child, <a href="#Page_182">182</a></span><br /> +<br /> +Hunger, of the newborn baby, <a href="#Page_105">105</a>, <a href="#Page_109">109</a><br /> +<br /> +Hypnotic suggestion, in treatment of enuresis, <a href="#Page_95">95</a><br /> +<br /> +Hypnotics, <a href="#Page_70">70</a>, <a href="#Page_71">71</a><br /> +<br /> +Hysteria, <a href="#Page_158">158</a><br /> +<span class="in1">age of appearance of, <a href="#Page_158">158</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_32">32</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_158">158</a></span><br /> +<br /> +Hysterical girls, characteristics of, <a href="#Page_32">32</a><br /> + <br /></p> + + +<p>Ideals, inculcation of, <a href="#Page_118">118</a>-119<br /> +<br /> +Ideas, polarisation and depolarisation of, <a href="#Page_172">172</a><br /> +<br /> +Illness. <i>See</i> Sickness<br /> +<br /> +Imagination, abnormal, correction of, <a href="#Page_138">138</a><br /> +<span class="in1">child's stories and tales in relation to, 137, 138</span><br /> +<span class="in1">developed by toys, <a href="#Page_98">98</a></span><br /> +<br /> +Imitativeness, age at which apparent, <a href="#Page_16">16</a><br /> +<span class="in1">extent of, <a href="#Page_23">23</a></span><br /> +<span class="in1">illustration of, <a href="#Page_17">17</a>, <a href="#Page_23">23</a></span><br /> +<span class="in1">lack of, <a href="#Page_56">56</a></span><br /> +<span class="in1">of action, <a href="#Page_19">19</a></span><br /> +<span class="in1">of speech, <a href="#Page_17">17</a>, <a href="#Page_18">18</a></span><br /> +<span class="in1">tell-tale child an illustration of, <a href="#Page_18">18</a></span><br /> + +<span class="pagenum">Page 196<a name="Page_196" id="Page_196"></a></span> + +<br /> +Incontinence of urine, <a href="#Page_89">89</a>-<a href="#Page_95">95</a><br /> +<br /> +Incorrigible children, <a href="#Page_129">129</a><br /> +<br /> +Infantile characteristics, <a href="#Page_146">146</a><br /> +<span class="in1">ductless glands in relation to, <a href="#Page_147">147</a></span><br /> +<span class="in1">nervous system in relation to, <a href="#Page_149">149</a>, <a href="#Page_150">150</a></span><br /> +<br /> +Infective disorders,<br /> +<span class="in1">convalescence from, <a href="#Page_157">157</a></span><br /> +<span class="in1">producing nervous symptoms, <a href="#Page_167">167</a></span><br /> +<span class="in1">relation of neurosis to, <a href="#Page_167">167</a></span><br /> +<br /> +Inflammatory reactions, <a href="#Page_147">147</a><br /> +<br /> +Insomnia. <i>See</i> Sleeplessness<br /> +<br /> +Intellect, compared with physique, <a href="#Page_120">120</a><br /> +<br /> +Intelligence, in early childhood, <a href="#Page_40">40</a>, <a href="#Page_41">41</a>, <a href="#Page_42">42</a><br /> +<br /> +Intestinal disturbance, <a href="#Page_54">54</a><br /> +<span class="in1">of neurosis, <a href="#Page_153">153</a></span><br /> +<span class="in1">symptom of, <a href="#Page_157">157</a></span><br /> +<br /> +Intoxications, violent reaction to, <a href="#Page_142">142</a><br /> +<br /> +Introspection, and neuropathic children, <a href="#Page_138">138</a><br /> +<span class="in1">excessive, evidences of, <a href="#Page_139">139</a></span><br /> +<span class="in2">influencing conduct, <a href="#Page_139">139</a></span><br /> +<br /> +Irritation, child to be free from, <a href="#Page_40">40</a><br /> + <br /></p> + +<p>Joint pains, <a href="#Page_167">167</a><br /> +<br /> +<br /> +Kindergarten school, artificial symbolism of, <a href="#Page_24">24</a><br /> +<br /> +Kindness, inculcation of, <a href="#Page_129">129</a><br /> + <br /> +</p> + +<p> +Lactation,<br /> +<span class="in1">care of child during, <a href="#Page_106">106</a>, <a href="#Page_109">109</a></span><br /> +<span class="in1">care of mother during, <a href="#Page_110">110</a></span><br /> +<span class="in1">causes of failure in, <a href="#Page_108">108</a></span><br /> +<span class="in1">establishment of, <a href="#Page_106">106</a>, <a href="#Page_107">107</a></span><br /> +<span class="in1">tongue-tie in relation to, <a href="#Page_12">12</a></span><br /> +<br /> +Laryngismus stridulus. <i>See</i> Breath-holding<br /> +<br /> +Later childhood,<br /> +<span class="in1">infantile characteristics in, <a href="#Page_146">146</a></span><br /> +<span class="in1">management in, <a href="#Page_117">117</a>-130</span><br /> +<span class="in1">mental backwardness in, <a href="#Page_146">146</a></span><br /> +<br /> +Likes and dislikes, <a href="#Page_25">25</a><br /> +<br /> +Lordosis, <a href="#Page_151">151</a><br /> +<span class="in1">and neurosis, <a href="#Page_151">151</a></span><br /> +<span class="in1">producing albuminuria, <a href="#Page_152">152</a></span><br /> + <br /></p> + +<p>Manual dexterity, advantages of, <a href="#Page_122">122</a><br /> +<br /> +Massage, improving tone of muscles, <a href="#Page_154">154</a><br /> +<br /> +Medicines, sensitiveness to, <a href="#Page_26">26</a><br /> +<br /> +Melancholy children, <a href="#Page_157">157</a><br /> +<br /> +Mental aspects, of digestive disorders, <a href="#Page_51">51</a>-54<br /> +<span class="in1">of enuresis, <a href="#Page_95">95</a></span><br /> +<span class="in1">of management in early childhood, <a href="#Page_31">31</a></span><br /> +<br /> +Mental backwardness,<br /> +<span class="in1">and infantile characteristics, <a href="#Page_146">146</a></span><br /> +<span class="in1">in later childhood, <a href="#Page_146">146</a></span><br /> +<br /> +Mental disturbances,<br /> +<span class="in1">cyclical character of, <a href="#Page_61">61</a></span><br /> +<span class="in1">indicating neuropathic tendencies, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">irregularities of sleep due to, <a href="#Page_68">68</a></span><br /> +<span class="in1">psycho-analysis of, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<br /> +Mental exhaustion,<br /> +<span class="in1">during convalescence from infective disorders, <a href="#Page_157">157</a></span><br /> +<span class="in1">easily produced in nervous children, <a href="#Page_143">143</a></span><br /> +<br /> +Mental irritability, chorea a symptom of, <a href="#Page_156">156</a><br /> +<br /> +Mental life of the child, <a href="#Page_101">101</a><br /> +<br /> +Mental power,<br /> +<span class="in1">active before beginning of speech, <a href="#Page_40">40</a></span><br /> +<span class="in1">in early childhood, <a href="#Page_40">40</a></span><br /> +<br /> +Mental processes, development of, <a href="#Page_5">5</a>, <a href="#Page_22">22</a>, <a href="#Page_23">23</a>, <a href="#Page_50">50</a><br /> +<span class="in1">age at which most apparent, <a href="#Page_16">16</a></span><br /> +<span class="in1">in later childhood, <a href="#Page_117">117</a></span><br /> +<span class="in1">effect of unconscious suggestions on, <a href="#Page_29">29</a></span><br /> +<span class="in1">heredity in relation to, <a href="#Page_10">10</a></span><br /> +<span class="in1">influence of environment on, <a href="#Page_10">10</a>, <a href="#Page_22">22</a></span><br /> +<br /> +Mental training, <a href="#Page_122">122</a><br /> +<span class="in1">compared with physical training, <a href="#Page_120">120</a></span><br /> +<span class="in1">objects and advantages of, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></span><br /> +<br /> +Mental unrest,<br /> +<span class="in1">avoidance of, <a href="#Page_67">67</a></span><br /> +<span class="in1">crying in relation to, <a href="#Page_67">67</a></span><br /> +<span class="in1">digestive disturbances due to, <a href="#Page_62">62</a></span><br /> +<span class="in1">growth of neuroses in atmosphere of, <a href="#Page_75">75</a></span><br /> + +<span class="pagenum">Page 197<a name="Page_197" id="Page_197"></a></span> + +<span class="in1">habitual actions in relation to, <a href="#Page_77">77</a></span><br /> +<span class="in1">in the adult, <a href="#Page_7">7</a></span><br /> +<span class="in1">in the child, <a href="#Page_6">6</a>, <a href="#Page_7">7</a></span><br /> +<span class="in1">negativism due to, <a href="#Page_60">60</a></span><br /> +<span class="in1">of newborn infant, effects of, <a href="#Page_107">107</a></span><br /> +<span class="in1"><i>See also</i> Nervous Unrest</span><br /> +<br /> +Micturition,<br /> +<span class="in1">functional disorder of, <a href="#Page_30">30</a></span><br /> +<span class="in1">negativism in, <a href="#Page_81">81</a></span><br /> +<span class="in1">regulation of, <a href="#Page_30">30</a></span><br /> +<span class="in1"><i>See also</i> Enuresis</span><br /> +<br /> +Migraine,<br /> +<span class="in1">periodic vomiting associated with, <a href="#Page_85">85</a></span><br /> +<span class="in1">symptom of nervous exhaustion, <a href="#Page_87">87</a></span><br /> +<br /> +Mind,<br /> +<span class="in1">and body, development of, <a href="#Page_120">120</a>, <a href="#Page_121">121</a></span><br /> +<span class="in1">effect on the body, <a href="#Page_51">51</a></span><br /> +<span class="in1">vigour of, in relation to that of body, <a href="#Page_120">120</a></span><br /> +<br /> +Money, theft of, <a href="#Page_127">127</a><br /> +<br /> +Montessori system of training, <a href="#Page_20">20</a>, <a href="#Page_23">23</a>, <a href="#Page_121">121</a><br /> +<br /> +Moral degeneracy, <a href="#Page_126">126</a><br /> +<br /> +Moral standard of school life, <a href="#Page_183">183</a><br /> +<br /> +Moral training, <a href="#Page_123">123</a><br /> +<span class="in1">importance and effects of, <a href="#Page_120">120</a></span><br /> +<span class="in1">negative virtues and, <a href="#Page_124">124</a></span><br /> +<span class="in1">objects and advantages of, <a href="#Page_123">123</a>, <a href="#Page_126">126</a></span><br /> +<span class="in1">parents' responsibilities in, <a href="#Page_123">123</a>, <a href="#Page_124">124</a></span><br /> +<br /> +Morals, public opinion forming code of, <a href="#Page_183">183</a><br /> +<br /> +Morbid introspection, <a href="#Page_139">139</a><br /> +<br /> +Mothers,<br /> +<span class="in1">ability and inability to manage children, <a href="#Page_8">8</a></span><br /> +<span class="in1">attitude in regard to temperament of child, <a href="#Page_10">10</a>, 11</span><br /> +<span class="in1">care of, during lactation, <a href="#Page_110">110</a></span><br /> +<span class="in1">conduct of child influenced by, <a href="#Page_11">11</a></span><br /> +<span class="in1">inability to understand nature of child's disorders, <a href="#Page_5">5</a></span><br /> +<span class="in1">influence of, on tone and manner of speech, <a href="#Page_17">17</a></span><br /> +<span class="in1">mental environment of child created by, <a href="#Page_8">8</a></span><br /> +<span class="in1">personality of, <a href="#Page_7">7</a></span><br /> +<span class="in1">relation to the child, <a href="#Page_101">101</a></span><br /> +<br /> +Motionless children, <a href="#Page_157">157</a><br /> +<br /> +Mouth, habit of conveying everything to, cause of, <a href="#Page_19">19</a><br /> +<br /> +Movements,<br /> +<span class="in1">precision of, <a href="#Page_20">20</a></span><br /> +<span class="in1">purposive, development of, <a href="#Page_19">19</a>, <a href="#Page_21">21</a></span><br /> +<span class="in1">self-command of, <a href="#Page_21">21</a></span><br /> +<br /> +Muscular atrophy, and neurosis, <a href="#Page_151">151</a><br /> +<br /> +Muscular system,<br /> +<span class="in1">changes in infantile children, <a href="#Page_148">148</a></span><br /> +<span class="in1">weak development of, <a href="#Page_151">151</a></span><br /> +<br /> +Muscular tone, how improved, <a href="#Page_154">154</a><br /> +<br /> +Myopathy, primary, <a href="#Page_151">151</a><br /> + <br /> +</p> + +<p> +Nasal obstruction<br /> +<span class="in1">and failure of lactation, <a href="#Page_12">12</a>, 108</span><br /> +<span class="in1">night-terrors aggravated by, <a href="#Page_136">136</a></span><br /> +<br /> +Natural history, sexual matters taught by, <a href="#Page_174">174</a><br /> +<br /> +Naughtiness, child's delight in, <a href="#Page_45">45</a><br /> +<br /> +Naughty, use of the term, <a href="#Page_44">44</a><br /> +<br /> +Negative virtues, and moral training, <a href="#Page_124">124</a><br /> +<br /> +Negativism, <a href="#Page_3">3</a>, <a href="#Page_12">12</a>, <a href="#Page_13">13</a><br /> +<span class="in1">cause of, <a href="#Page_60">60</a>, <a href="#Page_61">61</a></span><br /> +<span class="in1">characteristics, <a href="#Page_50">50</a></span><br /> +<span class="in1">factors developing, <a href="#Page_56">56</a></span><br /> +<span class="in1">in constipation, <a href="#Page_80">80</a></span><br /> +<span class="in1">in micturition, <a href="#Page_81">81</a></span><br /> +<span class="in1">spirit of, <a href="#Page_45">45</a></span><br /> +<span class="in1">treatment of, <a href="#Page_60">60</a></span><br /> +<span class="in1">want of sleep depending on, <a href="#Page_64">64</a></span><br /> +<br /> +Nerve centres, controlling movement, development of, <a href="#Page_21">21</a><br /> +<br /> +Nervous control, instability of, connection between bodily ailments<br /> +<span class="in1">and, <a href="#Page_120">120</a></span><br /> +<br /> +Nervous cough, <a href="#Page_73">73</a><br /> +<br /> +Nervous disorders,<br /> +<span class="in1">and psycho-analysis, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<span class="in1">common, causes, characteristics, and treatment, <a href="#Page_140">140</a>-142</span><br /> +<span class="in1">frequency of, <a href="#Page_50">50</a></span><br /> +<br /> +Nervous exhaustion, cyclic vomiting and migraine symptoms of, <a href="#Page_87">87</a><br /> +<br /> +Nervous instability, stigma of, <a href="#Page_140">140</a>-142<br /> + +<span class="pagenum">Page 198<a name="Page_198" id="Page_198"></a></span> + +<br /> +Nervous system, abnormal in children, <a href="#Page_149">149</a><br /> +<span class="in1">in relation to cyclic vomiting, <a href="#Page_85">85</a></span><br /> +<span class="in1">increased irritability of, <a href="#Page_81">81</a></span><br /> +<span class="in1">infantile characteristics of, <a href="#Page_149">149</a></span><br /> +<br /> +Nervous unrest, environment in relation to, <a href="#Page_142">142</a><br /> +<span class="in1">factors increasing, <a href="#Page_61">61</a></span><br /> +<span class="in1">manifestations of, <a href="#Page_73">73</a></span><br /> +<span class="in1">recurrence of periods of, <a href="#Page_61">61</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_6">6</a>, <a href="#Page_7">7</a></span><br /> +<span class="in1"><i>See also</i> Mental Unrest</span><br /> +<br /> +Nervous vomiting. <i>See</i> Vomiting<br /> +<br /> +Nervousness, and digestive disorders, <a href="#Page_53">53</a>, <a href="#Page_54">54</a><br /> +<span class="in1">and neuropathy, <a href="#Page_132">132</a>-135</span><br /> +<span class="in1">in early infancy, <a href="#Page_104">104</a></span><br /> +<span class="in1">in older children, <a href="#Page_131">131</a>-144</span><br /> +<span class="in1">parents' attitude causing, <a href="#Page_31">31</a></span><br /> +<br /> +Nettlerash, <a href="#Page_161">161</a><br /> +<br /> +Neurasthenia, <a href="#Page_157">157</a><br /> +<br /> +Neuropathic children, common symptoms of, <a href="#Page_140">140</a>-144<br /> +<span class="in1">conduct of, <a href="#Page_133">133</a></span><br /> +<span class="in1">faulty contact with environment in, <a href="#Page_138">138</a></span><br /> +<span class="in1">fear the prominent symptom of, <a href="#Page_133">133</a></span><br /> +<span class="in1">introspection and self-consciousness of, <a href="#Page_138">138</a></span><br /> +<span class="in1">management of, <a href="#Page_150">150</a></span><br /> +<span class="in1">training of, <a href="#Page_126">126</a></span><br /> +<br /> +Neuropathic tendencies, evidence of, in older children, <a href="#Page_133">133</a><br /> +<br /> +Neuropaths, adult, <a href="#Page_143">143</a><br /> +<span class="in1">faulty management in child life leading to, <a href="#Page_2">2</a>, <a href="#Page_14">14</a></span><br /> +<span class="in1">phenomena of, <a href="#Page_132">132</a></span><br /> +<span class="in1">phobias of, <a href="#Page_143">143</a></span><br /> +<span class="in1">selection of suitable environment for, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></span><br /> +<span class="in1">symptoms of, <a href="#Page_7">7</a></span><br /> +<br /> +Neuroses, and psycho-analysis, <a href="#Page_177">177</a>, <a href="#Page_180">180</a><br /> +<span class="in1">association of albuminuria with, <a href="#Page_153">153</a></span><br /> +<span class="in1">constipation frequently due to, <a href="#Page_80">80</a></span><br /> +<span class="in1">examination of, <a href="#Page_82">82</a></span><br /> +<span class="in1">growth in atmosphere of unrest and apprehension, <a href="#Page_75">75</a></span><br /> +<span class="in1">relation of, to infection of the body, <a href="#Page_167">167</a></span><br /> +<span class="in1">treatment of, <a href="#Page_153">153</a></span><br /> +<br /> +Neurotics, and physique, <a href="#Page_145">145</a>, <a href="#Page_151">151</a><br /> +<span class="in1">characteristics, <a href="#Page_131">131</a>, <a href="#Page_132">132</a></span><br /> +<span class="in1">exaggeration of emotions of, <a href="#Page_131">131</a></span><br /> +<br /> +Newborn baby, administration of sedatives to, <a href="#Page_110">110</a><br /> +<span class="in1">artificial feeding of, <a href="#Page_109">109</a>, <a href="#Page_113">113</a></span><br /> +<span class="in1">breast feeding of, <a href="#Page_106">106</a>, <a href="#Page_107">107</a></span><br /> +<span class="in1">case of, <a href="#Page_105">105</a>, <a href="#Page_109">109</a>, <a href="#Page_114">114</a>, <a href="#Page_115">115</a></span><br /> +<span class="in1">effect of mental unrest on, <a href="#Page_107">107</a></span><br /> +<span class="in1">first impressions of, <a href="#Page_104">104</a></span><br /> +<span class="in1">formation of habits of sleep and crying in, <a href="#Page_115">115</a></span><br /> +<span class="in1">heat and cold in relation to, <a href="#Page_106">106</a></span><br /> +<span class="in1">hunger of, <a href="#Page_105">105</a>, <a href="#Page_109">109</a></span><br /> +<span class="in1">induction of the sucking movements of, <a href="#Page_106">106</a></span><br /> +<span class="in1">of nervous inheritance, <a href="#Page_105">105</a></span><br /> +<span class="in1">personality of, <a href="#Page_104">104</a></span><br /> +<span class="in1">prevention of restlessness and crying, <a href="#Page_114">114</a>, <a href="#Page_115">115</a></span><br /> +<span class="in1">reduction of sense stimuli in, <a href="#Page_105">105</a></span><br /> +<span class="in1">reflex action of sucking in, <a href="#Page_108">108</a></span><br /> +<span class="in1">sense of taste of, <a href="#Page_113">113</a></span><br /> +<span class="in1">symptoms of dyspepsia in, <a href="#Page_116">116</a></span><br /> +<span class="in1">times of feeding, <a href="#Page_116">116</a></span><br /> +<span class="in1">weaning of, <a href="#Page_113">113</a>, <a href="#Page_114">114</a></span><br /> +<br /> +Night-terrors, aggravation of, <a href="#Page_70">70</a>, <a href="#Page_136">136</a><br /> +<span class="in1">causes of, <a href="#Page_135">135</a></span><br /> +<span class="in1">of neuropathic children, <a href="#Page_134">134</a></span><br /> +<br /> +Nursery, activities in, child's interest in, <a href="#Page_22">22</a>-23<br /> +<span class="in1">importance of child's being alone</span><br /> +<span class="in1">in, <a href="#Page_36">36</a>, <a href="#Page_38">38</a>, <a href="#Page_96">96</a>, <a href="#Page_99">99</a>, <a href="#Page_101">101</a></span><br /> +<span class="in1">observations in, <a href="#Page_16">16</a></span><br /> +<br /> +Nursery life, advantages of, <a href="#Page_9">9</a><br /> +<br /> +Nursery psycho-therapeutics, <a href="#Page_15">15</a><br /> +<br /> +Nurses, ability and inability to manage children, <a href="#Page_9">9</a><br /> +<span class="in1">influence of, on tone and manner of speech, <a href="#Page_17">17</a></span><br /> +<span class="in1">mental environment of child created by, <a href="#Page_8">8</a></span><br /> +<span class="in1">personality of, <a href="#Page_7">7</a></span><br /> +<br /> +Nursing, during sickness, <a href="#Page_166">166</a><br /> +<span class="in1">of the newborn infant, <a href="#Page_105">105</a>-115</span><br /> + <br /> +</p> + +<p><span class="pagenum">Page 199<a name="Page_199" id="Page_199"></a></span></p> + +<p>Obedience, <a href="#Page_49">49</a><br /> +<span class="in1">and perverse pleasure, <a href="#Page_34">34</a></span><br /> +<span class="in1">growth of, <a href="#Page_42">42</a></span><br /> +<br /> +Obsession of bed wetting, <a href="#Page_89">89</a>, <a href="#Page_91">91</a><br /> +<br /> +Opposition, <a href="#Page_61">61</a><br /> +<span class="in1">and counter-opposition, <a href="#Page_67">67</a>, <a href="#Page_179">179</a></span><br /> +<span class="in1">during sickness, <a href="#Page_160">160</a></span><br /> +<span class="in1">force of, factors influencing development, <a href="#Page_60">60</a></span><br /> +<span class="in1">habit of, <a href="#Page_59">59</a></span><br /> +<span class="in1">impulse of, <a href="#Page_35">35</a></span><br /> +<span class="in1">love of, in early childhood, <a href="#Page_59">59</a>, <a href="#Page_60">60</a></span><br /> +<span class="in1">to food, <a href="#Page_25">25</a></span><br /> +<br /> +Organic disturbance, in combination with functional trouble, <a href="#Page_4">4</a><br /> + <br /></p> + +<p>Pain, frequent loss of sense of, in neuropaths, <a href="#Page_138">138</a>, <a href="#Page_139">139</a><br /> +<br /> +Pallor, <a href="#Page_152">152</a><br /> +<span class="in1">sudden attacks of, <a href="#Page_141">141</a></span><br /> +<br /> +Palpitation, example of visceral fatigue, <a href="#Page_143">143</a><br /> +<br /> +Parathyroid glands, function of, <a href="#Page_147">147</a><br /> +<br /> +Parents,<br /> +<span class="in1">and children, conflict between, <a href="#Page_43">43</a>, <a href="#Page_44">44</a></span><br /> +<span class="in1">and silence on sexual matters, <a href="#Page_170">170</a></span><br /> +<span class="in1">habitual actions of, reproduced in the child, <a href="#Page_75">75</a></span><br /> +<span class="in1">mental attitude of, in relation to conduct, <a href="#Page_31">31</a></span><br /> +<span class="in1">over-exercise of authority by, results of, <a href="#Page_42">42</a>, <a href="#Page_43">43</a>, <a href="#Page_45">45</a></span><br /> +<span class="in1">responsibilities in moral training of child, <a href="#Page_123">123</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">suggestions unconsciously conveyed by, evil results of, <a href="#Page_31">31</a>, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<br /> +Parties, disadvantages of, <a href="#Page_102">102</a><br /> +<br /> +Patient, temperament of, physician in relation to, <a href="#Page_4">4</a><br /> +<br /> +Pelvis, development of, <a href="#Page_146">146</a><br /> +<br /> +Peripheral nerves, increase in irritability and conductivity of, <a href="#Page_81">81</a><br /> +<br /> +Personal adornment, delight in, <a href="#Page_48">48</a><br /> +<br /> +Personality,<br /> +<span class="in1">and disobedience, <a href="#Page_58">58</a></span><br /> +<span class="in1">child's own conception of, <a href="#Page_24">24</a>, <a href="#Page_129">129</a></span><br /> +<span class="in1">environment influencing, <a href="#Page_25">25</a></span><br /> +<span class="in1">in early childhood, <a href="#Page_32">32</a>, <a href="#Page_165">165</a></span><br /> +<span class="in1">of newborn baby, <a href="#Page_104">104</a></span><br /> +<br /> +Perspiration, abundant, sudden attacks of, <a href="#Page_141">141</a><br /> +<br /> +Phobias, 14<br /> +<span class="in1">characteristics and varieties, <a href="#Page_134">134</a>, <a href="#Page_135">135</a></span><br /> +<span class="in1">frequency of, <a href="#Page_134">134</a></span><br /> +<span class="in1">treatment of, <a href="#Page_135">135</a></span><br /> +<br /> +Physical defects, accompanying neurosis, <a href="#Page_145">145</a>, <a href="#Page_151">151</a><br /> +<br /> +Physical disturbances, due to emotion, <a href="#Page_53">53</a>, <a href="#Page_54">54</a><br /> +<br /> +Physical exercise, lack of, causing want of sleep, <a href="#Page_69">69</a><br /> +<br /> +Physical fatigue, easily produced in nervous children, <a href="#Page_143">143</a><br /> +<br /> +Physical phenomena of neuropaths, <a href="#Page_132">132</a><br /> +<br /> +Physical training, <a href="#Page_121">121</a><br /> +<span class="in1">objects and advantages of, <a href="#Page_121">121</a>, <a href="#Page_122">122</a>, <a href="#Page_126">126</a></span><br /> +<br /> +Physician,<br /> +<span class="in1">and the temperament of his patient, <a href="#Page_4">4</a></span><br /> +<span class="in1">examination by, <a href="#Page_2">2</a>, <a href="#Page_3">3</a>, <a href="#Page_13">13</a></span><br /> +<span class="in1">diagnosis by, <a href="#Page_2">2</a>, <a href="#Page_3">3</a>, <a href="#Page_13">13</a></span><br /> +<span class="in1">difficulties of, <a href="#Page_4">4</a></span><br /> +<br /> +Physique, intellect compared with, <a href="#Page_120">120</a><br /> +<br /> +Pica and dirt eating, <a href="#Page_80">80</a><br /> +<br /> +Picture books,<br /> +<span class="in1">educative value of, <a href="#Page_100">100</a></span><br /> +<span class="in1">kinds most suitable, <a href="#Page_99">99</a>, <a href="#Page_100">100</a></span><br /> +<br /> +Play,<br /> +<span class="in1">happiness of child during, <a href="#Page_96">96</a></span><br /> +<span class="in1">in the nursery, <a href="#Page_36">36</a>, <a href="#Page_37">37</a></span><br /> +<span class="in1">with grown-up persons, <a href="#Page_36">36</a>, <a href="#Page_38">38</a></span><br /> +<br /> +Pleasure, sense of, in early childhood, <a href="#Page_48">48</a><br /> +<br /> +Polarisation of ideas, <a href="#Page_172">172</a><br /> +<br /> +Postural albuminuria, <a href="#Page_152">152</a><br /> +<br /> +Posture, faulty, <a href="#Page_161">161</a>, <a href="#Page_162">162</a><br /> +<span class="in2">prevention of, <a href="#Page_154">154</a></span><br /> +<br /> +Power, child's love of, <a href="#Page_32">32</a>, <a href="#Page_59">59</a><br /> +<br /> +Precision of movement, development of, <a href="#Page_19">19</a>, <a href="#Page_96">96</a><br /> +<br /> +Psycho-analysis,<br /> +<span class="in1">dangers of, <a href="#Page_180">180</a></span><br /> +<span class="in1">observations on, <a href="#Page_176">176</a>, <a href="#Page_177">177</a></span><br /> +<br /> +Public schools, character and effects of, <a href="#Page_183">183</a><br /> + +<span class="pagenum">Page 200<a name="Page_200" id="Page_200"></a></span> + +<br /> +Punishment,<br /> +<span class="in1">deserved and undeserved, <a href="#Page_126">126</a></span><br /> +<span class="in1">frequent, disadvantages of, <a href="#Page_47">47</a></span><br /> +<span class="in1">observations on, <a href="#Page_39">39</a>, <a href="#Page_46">46</a></span><br /> +<br /> +Purity, inculcation of high ideals of, <a href="#Page_175">175</a><br /> +<br /> +Purposive movements, earliest,<br /> +<span class="in1">cause of, <a href="#Page_19">19</a></span><br /> +<span class="in1">encouragement of, <a href="#Page_24">24</a></span><br /> +<br /> +Pyloric spasm, <a href="#Page_112">112</a><br /> +<br /> +Pyrexia, <a href="#Page_88">88</a><br /> +<span class="in1">organic disease in relation to, <a href="#Page_88">88</a></span><br /> + <br /></p> + +<p> +Rational hygiene, <a href="#Page_5">5</a><br /> +<br /> +Reasoning power, <a href="#Page_40">40</a><br /> +<span class="in1">active before advent of speech, <a href="#Page_40">40</a></span><br /> +<span class="in1">factors influencing development of, <a href="#Page_40">40</a>, <a href="#Page_41">41</a>, <a href="#Page_117">117</a>, <a href="#Page_118">118</a></span><br /> +<br /> +Regulation of habits, <a href="#Page_30">30</a><br /> +<br /> +Repression, by older children of younger, <a href="#Page_47">47</a><br /> +<br /> +Reproduction, method of imparting knowledge of, <a href="#Page_174">174</a><br /> +<br /> +Reproof, <a href="#Page_20">20</a>, <a href="#Page_21">21</a>, <a href="#Page_24">24</a><br /> +<span class="in1">cases in which useless, <a href="#Page_60">60</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">causing disobedience, <a href="#Page_61">61</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">effects of, <a href="#Page_33">33</a>, <a href="#Page_36">36</a>, <a href="#Page_47">47</a>, <a href="#Page_124">124</a></span><br /> +<span class="in1">extreme sensitiveness to, 46</span><br /> +<span class="in1">perverse pleasure of, <a href="#Page_34">34</a></span><br /> +<span class="in1">too frequent repetition of, futility of, <a href="#Page_44">44</a>, <a href="#Page_45">45</a>, <a href="#Page_47">47</a>, <a href="#Page_60">60</a>, <a href="#Page_124">124</a>, <a href="#Page_125">125</a></span><br /> +<br /> +Restlessness, during sickness, <a href="#Page_160">160</a><br /> +<br /> +Rewards, use and dangers of, <a href="#Page_48">48</a><br /> +<br /> +Rheumatism, <a href="#Page_155">155</a><br /> +<span class="in1">and chorea, association between, <a href="#Page_155">155</a></span><br /> +<span class="in1">characteristics in childhood, <a href="#Page_156">156</a></span><br /> +<span class="in1">subacute, <a href="#Page_167">167</a></span><br /> +<span class="in1">treatment of, <a href="#Page_156">156</a></span><br /> +<br /> +Rickets,<br /> +<span class="in1">mental and intellectual condition in, <a href="#Page_120">120</a></span><br /> +<span class="in1">in infantile children, <a href="#Page_148">148</a></span><br /> +<span class="in1">occurrence with spasmophilia, <a href="#Page_82">82</a></span><br /> +<br /> +Right and wrong, appreciation of, in early childhood, <a href="#Page_42">42</a><br /> +<br /> +Round shoulders, <a href="#Page_151">151</a><br /> + <br /></p> + +<p> +St. Vitus's dance, <a href="#Page_167">167</a><br /> +<br /> +Salts, excretion of, <a href="#Page_147">147</a><br /> +<br /> +School life, <a href="#Page_182">182</a>, <a href="#Page_184">184</a><br /> +<span class="in1">and sexual matters, <a href="#Page_171">171</a>, <a href="#Page_175">175</a></span><br /> +<span class="in1">moral standard of, <a href="#Page_183">183</a></span><br /> +<span class="in1">moral training and, <a href="#Page_123">123</a></span><br /> +<span class="in1">moulding of character during, <a href="#Page_184">184</a></span><br /> +<span class="in1">of boys, <a href="#Page_183">183</a>-187</span><br /> +<span class="in1">of girls, <a href="#Page_188">188</a></span><br /> +<br /> +Schools, public, character and effects of, <a href="#Page_183">183</a><br /> +<br /> +Scoliosis, prevention of, <a href="#Page_154">154</a><br /> +<br /> +Secretions, anomalies of, <a href="#Page_141">141</a><br /> +<br /> +Self, child's conception of, <a href="#Page_48">48</a><br /> +<br /> +Self-conscious children, complaints of, <a href="#Page_139">139</a><br /> +<br /> +Self-consciousness, of neuropathic children, <a href="#Page_138">138</a><br /> +<br /> +Self-discipline, development of, <a href="#Page_125">125</a>, <a href="#Page_126">126</a><br /> +<br /> +Self-education, in the nursery, <a href="#Page_96">96</a><br /> +<br /> +Self-feeding, <a href="#Page_55">55</a><br /> +<br /> +Self-preservation, morbid instinct of, <a href="#Page_134">134</a><br /> +<br /> +Self-sacrifice, not to be expected in early childhood, <a href="#Page_48">48</a>-49<br /> +<br /> +Sensations,<br /> +<span class="in1">acuteness of, <a href="#Page_69">69</a></span><br /> +<span class="in1">bodily, of neuropaths, <a href="#Page_138">138</a></span><br /> +<br /> +Sense perception, of neuropaths, <a href="#Page_132">132</a><br /> +<br /> +Sense stimuli,<br /> +<span class="in1">cultivation of perception of, <a href="#Page_23">23</a></span><br /> +<span class="in1">in newborn babies, <a href="#Page_105">105</a></span><br /> +<br /> +Sexual matters,<br /> +<span class="in1">education on, <a href="#Page_168">168</a></span><br /> +<span class="in1">method of, <a href="#Page_174">174</a></span><br /> +<span class="in1">errors of conduct and, <a href="#Page_176">176</a></span><br /> +<span class="in1">parents' silence in regard to, <a href="#Page_170">170</a></span><br /> +<span class="in1">psycho-analysis in relation to, <a href="#Page_177">177</a>, <a href="#Page_178">178</a></span><br /> +<span class="in1">school life in relation to, <a href="#Page_171">171</a>, <a href="#Page_175">175</a></span><br /> +<br /> +Sickness, <a href="#Page_160">160</a><br /> +<span class="in1">evil effects of suggestions unconsciously conveyed by parents</span><br /> +<span class="in2">during, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<span class="in1">management during, <a href="#Page_160">160</a>, <a href="#Page_163">163</a></span><br /> +<span class="in1">nurse and mother during, <a href="#Page_166">166</a></span><br /> +<span class="in1">opposition during, <a href="#Page_160">160</a></span><br /> +<span class="in1">temperature during, <a href="#Page_161">161</a></span><br /> +<span class="in1">therapeutic measures in, <a href="#Page_164">164</a></span><br /> +<span class="in1">therapeutic procedures concentrating child's mind on his symptoms, <a href="#Page_163">163</a></span><br /> + +<span class="pagenum">Page 201<a name="Page_201" id="Page_201"></a></span> + +<br /> +Sleep, estimation of the amount of, <a href="#Page_136">136</a><br /> +<span class="in1">force of suggestion in relation to, <a href="#Page_27">27</a>, <a href="#Page_28">28</a></span><br /> +<span class="in1">formation of habit of, <a href="#Page_115">115</a></span><br /> +<span class="in1">light and broken, cause of, <a href="#Page_68">68</a>, <a href="#Page_136">136</a>, <a href="#Page_137">137</a></span><br /> +<span class="in2">of newborn infant, <a href="#Page_114">114</a></span><br /> +<span class="in1">sound, beneficial effects of, <a href="#Page_71">71</a></span><br /> +<br /> +Sleeping attire, <a href="#Page_69">69</a><br /> +<br /> +Sleeplessness, breaking of the habit of, <a href="#Page_70">70</a><br /> +<span class="in1">causes and characteristics, <a href="#Page_64">64</a></span><br /> +<span class="in1">drugs in, <a href="#Page_70">70</a>, <a href="#Page_71">71</a></span><br /> +<span class="in1">in older children, <a href="#Page_136">136</a></span><br /> +<span class="in1">lack of physical exercise causing, <a href="#Page_69">69</a></span><br /> +<span class="in1">suggestion in relation to, <a href="#Page_27">27</a>, <a href="#Page_28">28</a>, <a href="#Page_70">70</a></span><br /> +<span class="in1">treatment of, <a href="#Page_67">67</a>, <a href="#Page_70">70</a>, <a href="#Page_137">137</a></span><br /> +<br /> +Sleep-walking, <a href="#Page_137">137</a><br /> +<br /> +Snatching, habit of, <a href="#Page_20">20</a><br /> +<br /> +Spasmophilia, <a href="#Page_81">81</a><br /> +<span class="in1">ætiology of, <a href="#Page_81">81</a></span><br /> +<span class="in1">drugs in treatment of, <a href="#Page_84">84</a></span><br /> +<span class="in1">occurrence of rickets with, <a href="#Page_82">82</a></span><br /> +<br /> +Spasms, control of, <a href="#Page_84">84</a><br /> +<span class="in1">fatal, <a href="#Page_83">83</a></span><br /> +<br /> +Speech, beginnings of, <a href="#Page_17">17</a>, <a href="#Page_18">18</a><br /> +<span class="in1">facility with which local accent is acquired, <a href="#Page_17">17</a></span><br /> +<span class="in1">imitativeness of, <a href="#Page_17">17</a>, <a href="#Page_18">18</a></span><br /> +<span class="in1">infant's reasoning power present before advent of, <a href="#Page_40">40</a></span><br /> +<span class="in1">influence of nurses and mothers on tone and manner of, <a href="#Page_17">17</a></span><br /> +<br /> +Spinal deformity, prevention of, <a href="#Page_154">154</a><br /> +<br /> +Spinal muscles, atrophy of, <a href="#Page_151">151</a><br /> +<br /> +Spoon feeding, <a href="#Page_113">113</a><br /> +<br /> +Status catarrhalis, <a href="#Page_150">150</a><br /> +<br /> +Status lymphaticus, <a href="#Page_150">150</a><br /> +<br /> +Story-telling, <a href="#Page_99">99</a>, <a href="#Page_100">100</a><br /> +<br /> +Sucking movements, of newborn child, induction of, <a href="#Page_106">106</a><br /> +<span class="in1"><i>see also</i> Lactation</span><br /> +<br /> +Suggestion, and habit spasms, <a href="#Page_74">74</a><br /> +<span class="in1">appetite in relation to, <a href="#Page_52">52</a></span><br /> +<span class="in1">bed wetting in relation to, <a href="#Page_89">89</a></span><br /> +<span class="in1">bodily habits in relation to, <a href="#Page_30">30</a></span><br /> +<span class="in1">characteristics, <a href="#Page_24">24</a></span><br /> +<span class="in1">conduct influenced by, <a href="#Page_13">13</a>, <a href="#Page_130">130</a></span><br /> +<span class="in1">constipation in relation to, <a href="#Page_80">80</a></span><br /> +<span class="in1">effect on mental processes, <a href="#Page_29">29</a></span><br /> +<span class="in1">food in relation to, <a href="#Page_25">25</a></span><br /> +<span class="in1">force of, on child's mind, <a href="#Page_27">27</a>, <a href="#Page_75">75</a></span><br /> +<span class="in1">hysteria in relation to, <a href="#Page_32">32</a></span><br /> +<span class="in1">perverse influence of, <a href="#Page_29">29</a>, <a href="#Page_30">30</a></span><br /> +<span class="in2">bad habits due to, <a href="#Page_89">89</a>, <a href="#Page_90">90</a></span><br /> +<span class="in2">causing constipation, <a href="#Page_30">30</a></span><br /> +<span class="in2">want of sleep depending upon, <a href="#Page_64">64</a></span><br /> +<span class="in1">refusal of food in relation to, <a href="#Page_57">57</a>, <a href="#Page_58">58</a></span><br /> +<span class="in1">sleep in relation to, <a href="#Page_27">27</a></span><br /> +<span class="in1">susceptibility to, <a href="#Page_29">29</a>, <a href="#Page_57">57</a></span><br /> +<span class="in1">unconsciously conveyed by parents, evil results of, <a href="#Page_31">31</a>, <a href="#Page_164">164</a>, <a href="#Page_166">166</a></span><br /> +<br /> +Suicide, <a href="#Page_52">52</a><br /> +<br /> +Suspicions, aroused in the child, <a href="#Page_57">57</a>, <a href="#Page_58">58</a><br /> +<br /> +Syncopal attacks, causes and characteristics, <a href="#Page_140">140</a>, <a href="#Page_141">141</a><br /> + <br /></p> + +<p> +Tactile sensation. <i>See</i> Touch<br /> +<br /> +Taste, perversion of, <a href="#Page_26">26</a>, <a href="#Page_57">57</a><br /> +<span class="in1">sensations of, <a href="#Page_25">25</a></span><br /> +<span class="in2">how controlled, <a href="#Page_26">26</a></span><br /> +<span class="in1">sense of, in newborn infant, <a href="#Page_113">113</a></span><br /> +<br /> +Teething convulsions, <a href="#Page_148">148</a><br /> +<br /> +Tell-tale child, characteristics, <a href="#Page_18">18</a><br /> +<br /> +Temperament, diversity of, <a href="#Page_10">10</a><br /> +<span class="in1">heredity and, <a href="#Page_10">10</a></span><br /> +<span class="in1">mother's attitude in relation to, <a href="#Page_10">10</a>, <a href="#Page_11">11</a></span><br /> +<span class="in1">of the patient, physician in relation to, <a href="#Page_4">4</a></span><br /> +<br /> +Temperature, during sickness, <a href="#Page_161">161</a><br /> +<span class="in1">inexplicable rises in, <a href="#Page_88">88</a></span><br /> +<br /> +Terror, causes, of, <a href="#Page_28">28</a><br /> +<br /> +Tetany, liability to, in increased irritability of nervous system, <a href="#Page_81">81</a><br /> +<span class="in1">pressure to brachial nerve causing, <a href="#Page_81">81</a></span><br /> +<br /> +Theatres, disadvantages of, <a href="#Page_103">103</a><br /> +<br /> +Theft, <a href="#Page_52">52</a>, <a href="#Page_127">127</a><br /> +<br /> +Therapeutic conversation, <a href="#Page_124">124</a>, <a href="#Page_125">125</a><br /> + +<span class="pagenum">Page 202<a name="Page_202" id="Page_202"></a></span> + +<br /> +Thigh rubbing,<br /> +<span class="in1">avoidance of, <a href="#Page_78">78</a></span><br /> +<span class="in1">characteristics, <a href="#Page_78">78</a></span><br /> +<span class="in1">habitual action of, <a href="#Page_78">78</a></span><br /> +<br /> +Thorax, development of, <a href="#Page_146">146</a><br /> +<br /> +Thumb sucking, <a href="#Page_78">78</a>, <a href="#Page_79">79</a><br /> +<span class="in1">persistence of the habit, <a href="#Page_79">79</a></span><br /> +<br /> +Tongue-tie, in relation to lactation, <a href="#Page_12">12</a><br /> +<br /> +Tonics, <a href="#Page_155">155</a><br /> +<br /> +Tonsils, removal of, in treatment of enuresis, <a href="#Page_93">93</a><br /> +<br /> +Touch, sense of,<br /> +<span class="in1">cultivation of, <a href="#Page_23">23</a></span><br /> +<span class="in1">early development of, <a href="#Page_19">19</a>, <a href="#Page_20">20</a></span><br /> +<span class="in1">organs with greatest development of, <a href="#Page_19">19</a></span><br /> +<br /> +Toys,<br /> +<span class="in1">child's interest in, <a href="#Page_36">36</a></span><br /> +<span class="in1">educative value of, <a href="#Page_96">96</a>, <a href="#Page_98">98</a></span><br /> +<span class="in1">kind most suitable, <a href="#Page_97">97</a></span><br /> +<br /> +Training, early, importance and object of, <a href="#Page_2">2</a><br /> +<br /> +Trousseau's sign, nature and production of, <a href="#Page_81">81</a><br /> +<br /> +Truthfulness, <a href="#Page_123">123</a>, <a href="#Page_124">124</a><br /> +<span class="in1">inculcation of, <a href="#Page_128">128</a></span><br /> +<br /> +Twitching of facial muscles, <a href="#Page_81">81</a>, <a href="#Page_83">83</a><br /> +<br /> +Tyranny of tears, <a href="#Page_116">116</a><br /> + <br /></p> + +<p>Unkindness, habitual, of children to others, <a href="#Page_129">129</a><br /> +<br /> +Untruthfulness, <a href="#Page_126">126</a><br /> +<span class="in1">over-exercise of authority encouraging, <a href="#Page_43">43</a></span><br /> +<br /> +Urine,<br /> +<span class="in1">condition in enuresis, <a href="#Page_93">93</a></span><br /> +<span class="in1">incontinence of, methods of treatment, <a href="#Page_92">92</a>, <a href="#Page_93">93</a></span><br /> +<span class="in2"><i>See also</i> Enuresis</span><br /> +<span class="in1">increased secretion of, <a href="#Page_141">141</a></span><br /> +<span class="in1">irritation of, <a href="#Page_148">148</a></span><br /> + <br /></p> + +<p>Vasomotor instability,<br /> +<span class="in1">conditions indicating, <a href="#Page_140">140</a>, <a href="#Page_141">141</a></span><br /> +<span class="in1">in neuropaths, <a href="#Page_152">152</a></span><br /> +<br /> +Vasomotor tone, how improved, <a href="#Page_154">154</a><br /> +<br /> +Virtuous, definition of the term, <a href="#Page_183">183</a><br /> +<br /> +Visceral fatigue, easily produced in nervous children, <a href="#Page_143">143</a><br /> +<br /> +Vocabulary, <a href="#Page_18">18</a><br /> +<br /> +Voice, tone of, <a href="#Page_17">17</a><br /> +<br /> +Voluntary movements, development of cerebral centres controlling, <a href="#Page_19">19</a><br /> +<br /> +Vomiting, cyclic, <a href="#Page_50">50</a>, <a href="#Page_55">55</a><br /> +<span class="in1">ætiology of, <a href="#Page_85">85</a></span><br /> +<span class="in1">age at which it occurs, <a href="#Page_86">86</a></span><br /> +<span class="in1">case illustrating, <a href="#Page_51">51</a></span><br /> +<span class="in1">causes and characteristics, <a href="#Page_62">62</a>, <a href="#Page_86">86</a></span><br /> +<span class="in1">class of child affected by, <a href="#Page_87">87</a></span><br /> +<span class="in1">condition of the child during, <a href="#Page_86">86</a></span><br /> +<span class="in1">frequency of attacks, <a href="#Page_86">86</a></span><br /> +<span class="in1">migraine in association with, <a href="#Page_85">85</a></span><br /> +<span class="in1">nervous system in relation to, <a href="#Page_85">85</a>, <a href="#Page_87">87</a></span><br /> +<span class="in1">treatment of, <a href="#Page_62">62</a>, <a href="#Page_63">63</a>, <a href="#Page_87">87</a></span><br /> + <br /></p> + +<p> +Waking states, <a href="#Page_136">136</a><br /> +<br /> +Weaning, difficulty in, <a href="#Page_113">113</a>, <a href="#Page_114">114</a><br /> +<br /> +Will, strength of, absence in childhood, <a href="#Page_34">34</a><br /> +<br /> +Work and play, differentiation between, <a href="#Page_123">123</a><br /> +<br /> +Writing, correct posture during, <a href="#Page_155">155</a><br /> +</p> +<p> </p> + +<hr /> + +<p> +Transcriber's Notes<br /> +<br /> +The following typographical errors were corrected:<br /> +Page 4: 'sensisive' changed to 'sensitive'.<br /> +Page 48: 'self-abnegnation' changed to 'self-abnegation'.<br /> +Page 61: fixed 'and and'.<br /> +Page 125: 'acount' changed to 'account'.<br /> +First page of index (191): 'ullimentary' changed to 'Allimentary';<br /> + also 'ilstrating' channged to 'illustrating'.<br /> +</p> + + + + + + + + +<pre> + + + + + +End of 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: The Nervous Child + +Author: Hector Charles Cameron + +Release Date: December 29, 2004 [EBook #14515] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK THE NERVOUS CHILD *** + + + + +Produced by Audrey Longhurst, Ronald Holder and the PG Online +Distributed Proofreading Team + + + + + + +THE NERVOUS CHILD + + + + +PUBLISHED BY THE JOINT COMMITTEE OF +HENRY FROWDE, HODDER & STOUGHTON +17 WARWICK SQUARE, LONDON, E.C. 4 + + + + +THE + +NERVOUS CHILD + + +BY + +HECTOR CHARLES CAMERON +M.A., M.D.(CANTAB.), F.R.C.P.(LOND.) +PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF +THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL + + + "RESPECT the child. Be not too much his parent. Trespass not on + his solitude."--EMERSON. + + +LONDON +HENRY FROWDE HODDER & STOUGHTON +OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C. +1920 + + + + +_First Edition_ 1919 +_Second Impression_ 1930 + + + + +PRINTED IN GREAT BRITAIN +BY MORRISON & GIBB LTD., EDINBURGH + + + + +PREFACE + + +To-day on all sides we hear of the extreme importance of Preventive +Medicine and the great future which lies before us in this aspect of +our work. If so, it follows that the study of infancy and childhood +must rise into corresponding prominence. More and more a considerable +part of the Profession must busy itself in nurseries and in schools, +seeking to apply there the teachings of Psychology, Physiology, +Heredity, and Hygiene. To work of this kind, in some of its aspects, +this book may serve as an introduction. It deals with the influences +which mould the mentality of the child and shape his conduct. Extreme +susceptibility to these influences is the mark of the nervous child. + +I have to thank the Editors of _The Practitioner_ and of _The Child_, +respectively, for permission to reprint the chapters which deal with +"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I +should also like to offer thanks for helpful suggestions. + +H.C.C. + +_March_ 1919. + + + + +CONTENTS + +CHAP. PAGE + + I. DOCTORS, MOTHERS, AND CHILDREN 1 + + II. OBSERVATIONS IN THE NURSERY 16 + + III. WANT OF APPETITE AND INDIGESTION 50 + + IV. WANT OF SLEEP 64 + + V. SOME OTHER SIGNS OF NERVOUSNESS 73 + + VI. ENURESIS 89 + + VII. TOYS, BOOKS, AND AMUSEMENTS 96 + +VIII. NERVOUSNESS IN EARLY INFANCY 104 + + IX. MANAGEMENT IN LATER CHILDHOOD 117 + + X. NERVOUSNESS IN OLDER CHILDREN 131 + + XI. NERVOUSNESS AND PHYSIQUE 145 + + XII. THE NERVOUS CHILD IN SICKNESS 160 + +XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS 169 + + XIV. THE NERVOUS CHILD AND SCHOOL 182 + + INDEX 191 + + + + +THE NERVOUS CHILD + +CHAPTER I + +DOCTORS, MOTHERS, AND CHILDREN + + +There is an old fairy story concerning a pea which a princess once +slept upon--a little offending pea, a minute disturbance, a trifling +departure from the normal which grew to the proportions of intolerable +suffering because of the too sensitive and undisciplined nervous +system of Her Royal Highness. The story, I think, does not tell us +much else concerning the princess. It does not tell us, for instance, +if she was an only child, the sole preoccupation of her parents and +nurses, surrounded by the most anxious care, reared with some +difficulty because of her extraordinary "delicacy," suffering from a +variety of illnesses which somehow always seemed to puzzle the +doctors, though some of the symptoms--the vomiting, for example, and +the high temperature--were very severe and persistent. Nor does it +tell us if later in life, but before the suffering from the pea arose, +she had been taken to consult two famous doctors, one of whom had +removed the vermiform appendix, while the other a little later had +performed an operation for "adhesions." At any rate, the story with +these later additions, which are at least in keeping with what we know +of her history, would serve to indicate the importance which attaches +to the early training of childhood. Among the children even of the +well-to-do often enough the hygiene of the mind is overlooked, and +faulty management produces restlessness, instability, and +hyper-sensitiveness, which pass insensibly into neuropathy in adult +life. + +To prevent so distressing a result is our aim in the training of +children. No doubt the matter concerns in the first place parents and +nurses, school masters and mistresses, as well as medical men. Yet +because of the certainty that physical disturbances of one sort or +another will follow upon nervous unrest, it will seldom happen that +medical advice will not be sought sooner or later; and if the +physician is to intervene with success, he must be prepared with +knowledge of many sorts. He must be prepared to make a thorough and +complete physical examination, sufficient to exclude the presence of +organic disease. If no organic disease is found, he must explore the +whole environment of the child, and seek to determine whether the +exciting cause is to be found in the reaction of the child to some +form of faulty management. + +For example, a child of two or three years of age may be brought to +the doctor with the complaint that defaecation is painful, and that +there has existed for some time a most distressing constipation which +has resisted a large number of purgatives of increasing strength. +Whenever the child is placed upon the stool, his crying at once +begins, and no attempts to soothe or console him have been successful. +It is not sufficient for the doctor in such a case to make an +examination which convinces him that there is no fissure at the anus +and no fistula or thrombosed pile, and to confine himself to saying +that he can find nothing the matter. The crying and refusal to go to +stool will continue after the visit as before, and the mother will be +apt to conclude that her doctor, though she has the greatest +confidence in him for the ailments of grown-up persons, is unskilled +in, or at least not interested in, the diseases of little children. +If, on the other hand, the doctor pursues his inquiries into the +management of the child in the home, and if, for example, he finds +that the crying and resistance is not confined to going to stool, but +also takes place when the child is put to bed, and very often at +meal-times as well, then it will be safe for him to conclude that all +the symptoms are due to the same cause--a sort of "negativism" which +is apt to appear in all children who are directed and urged too much, +and whose parents are not careful to hide from them the anxiety and +distress which their conduct occasions. + +If this diagnosis is made, then a full and clear explanation should be +given to the mother, or at any rate to such mothers--and fortunately +they are in the majority--who are capable of appreciating the point of +psychology involved, and of correcting the management of the child so +as to overcome the negativism. To attempt treatment by prescribing +drugs, or in any other way than by correcting the faulty management, +is to court failure. As Charcot has said, in functional disorders it +is not so much the prescription which matters as the prescriber. + +But the task of the doctor is often one of even greater difficulty. +Often enough there will be a combination of organic disturbance with +functional trouble. For example, a girl of eighteen years old suffered +from a pain in the left arm which has persisted on and off since the +olecranon had been fractured when she was two years of age. She was +the youngest of a large family, and had never been separated for a day +from the care and apprehensions of her mother. The joint was stiff, +and there was considerable deformity. The pain always increased when +she was tired or unhappy. Again, a girl had some slight cystitis with +frequent micturition, and this passed by slow degrees into a purely +functional irritability of the bladder, which called for micturition +at frequent intervals both by day and night. In such cases treatment +must endeavour to control both factors--the local organic disturbance +must if possible be removed, and the faults of management corrected. + +It is a good physician who can appreciate and estimate accurately the +temperament of his patient, and the need for this insight is nowhere +greater than in dealing with the disorders of childhood. It can be +acquired only by long practice and familiarity with children. In the +hospital wards we shall learn much that is essential, but we shall not +learn this. The child, who is so sensitive to his environment, shows +but little that is characteristic when admitted to an institution. +Only in the nursery can we learn to estimate the influences which +proceed from parents and nurses of different characters and +temperaments, and the reaction which is produced by them in the child. + +The body of the child is moulded and shaped by the environment in +which it grows. Pure air, a rational diet, free movement, give +strength and symmetry to every part. Faults of hygiene debase the +type, although the type is determined by heredity which in the +individual is beyond our control. Mothers and nurses to-day are well +aware of the need for a rational hygiene. Mother-craft is studied +zealously and with success, and there is no lack of books to give +sound guidance and to show the mean between the dangerous extremes of +coddling and a too Spartan exposure. Yet sometimes it has seemed as if +some mothers whose care for their children's physical health is most +painstaking, who have nothing to learn on the question of diet, of +exercise, of fresh air, or of baths, who measure and weigh and record +with great minuteness, have had their attention so wholly occupied +with the care of the body that they do not appreciate the simultaneous +growth of the mind, or inquire after its welfare. Yet it is the +astounding rapidity with which the mental processes develop that forms +the distinguishing characteristic of the infancy of man. Were it not +for this rapid growth of the cerebral functions, the rearing of +children would be a matter almost as simple and uneventful as the +rearing of live stock. For most animals faults of environment must be +very pronounced to do harm by producing mental unrest and +irritability. Thus, indeed, some wild animal separated from its +fellows and kept in solitary captivity may sicken and waste, though +maintained and fed with every care. Yet if the whole conditions of +life for the animal are not profoundly altered, if the environment is +natural or approximately natural, it is as a rule necessary to care +only for its physical needs, and we need not fear that the results +will be spoiled by the reaction of the mind upon the body. But with +the child it is different; airy nurseries, big gardens, visits to the +seaside, and every advantage that money can buy cannot achieve success +if the child's mind is not at rest, if his sleep is broken, if food is +habitually refused or vomited, or if to leave him alone in the nursery +for a moment is to evoke a fit of passionate crying. + +The grown-up person comes eventually to be able to control this +tremendous organ, this brain, which is the predominant feature of his +race. In the child its functions are always unstable and liable to be +upset. Evidence of mental unrest or fatigue, which is only rarely met +with in grown persons and which then betokens serious disturbance of +the mind, is of comparatively common occurrence in little children. +Habit spasm, bed-wetting, sleep-walking, night terrors, and +convulsions are symptoms which are frequent enough in children, and +there is no need to be unduly alarmed at their occurrence. In adult +age they are found only among persons who must be considered as +neuropathic. To make the point clear, I have chosen examples from the +graver and more serious symptoms of nervous unrest. But it is equally +true that minor symptoms which in adults are universally recognised to +be dependent upon cerebral unrest or fatigue are of everyday +occurrence in childhood. Broken and disturbed sleep, absence of +appetite and persistent refusal of food, gastric pain and discomfort +after meals, nervous vomiting, morbid flushing and blushing, headache, +irritability and excessive emotional display, at whatever age they +occur, are indications of a mind that is not at rest. In children, as +in adults, they may be prominent although the physical surroundings of +the patient may be all that could be desired and all that wealth can +procure. It is an everyday experience that business worries and +responsibilities in men, domestic anxieties or childlessness in women, +have the power to ruin health, even in those who habitually or grossly +break none of its laws. The unstable mind of the child is so sensitive +that cerebral fatigue and irritability are produced by causes which +seem to us extraordinarily trivial. In the little life which the child +leads, a life in which the whole seems to us to be comprised in +dressing and undressing, washing, walking, eating, sleeping, and +playing, it is not easy to detect where the elements of nervous +overstrain lie. Nor is it as a rule in these things that the mischief +is to be found. It is in the personality of mother or nurse, in her +conduct to the child, in her actions and words, in the tone of her +voice when she addresses him, even in the thoughts which pass through +her mind and which show themselves plainly to that marvellously acute +intuition of his, which divines what she has not spoken, that we must +seek for the disturbing element. The mental environment of the child +is created by the mother or the nurse. That is her responsibility and +her opportunity. The conduct of the child must be the criterion of her +success. If things go wrong, if there is constant crying or +ungovernable temper, if sleep and food are persistently refused, or if +there is undue timidity and tearfulness, there is danger that seeds +may be sown from which nervous disorders will spring in the future. + +There are many women who, without any deep thought on the matter, have +the inborn knack of managing children, who seem to understand them, +and have a feeling for them. With them, we say, the children are +always good, and they are good because the element of nervous +overstrain has not arisen. There are other women, often very fond of +children, who are conspicuously lacking in this power. Contact with +one of these well-meaning persons, even for a few days, will +demoralise a whole nursery. Tempers grow wild and unruly, sleep +disappears, fretfulness and irritability take its place. Yet of most +mothers it is probably true that they are neither strikingly +proficient nor utterly deficient in the power of managing children. If +they lack the gift that comes naturally to some women, they learn from +experience and grow instinctively to feel when they have made a false +step with the child. Although by dearly bought experience they learn +wisdom in the management of their children, they nevertheless may not +study the subject with the same care which they devote to matters of +diet and hygiene. It is the mother whose education and understanding +best fits her for this task. In this country a separate nursery and a +separate nursery life for the children is found in nearly all +households among the well-to-do, and the care for the physical needs +of the children is largely taken off the mothers' shoulders by nurses +and nursemaids. That this arrangement is advantageous on the whole +cannot be doubted. In America and on the Continent, where the children +often mingle all day in the general life of the household, and occupy +the ordinary living rooms, experience shows that nerve strain and its +attendant evils are more common than with us. Nevertheless, the +arrangement of a separate nursery has its disadvantages. Nurses are +sometimes not sufficiently educated to have much appreciation of the +mental processes of the child. If the children are restless and +nervous they are content to attribute this to naughtiness or to +constipation, or to some other physical ailment. Their time is usually +so fully occupied that they cannot be expected to be very zealous in +reading books on the management of children. Nevertheless, in +practical matters of detail a good nurse will learn rapidly from a +mother who has given some attention to the subject, and who is able to +give explicit instructions upon definite points. + +It is right that mothers should appreciate the important part which +the environment plays in all the mental processes of children, and in +their physical condition as well; that they should understand that +good temper and happiness mean a proper environment, and that constant +crying and fretfulness, broken sleep, refusal of food, vomiting, undue +thinness, and extreme timidity often indicate that something in this +direction is at fault. + +Nevertheless, we must be careful not to overstate our case. We must +remember how great is the diversity of temperament in children--a +diversity which is produced purely by hereditary factors. The task of +all mothers is by no means of equal difficulty. There are children in +whom quite gross faults in training produce but little permanent +damage; there are others of so sensitive a nervous organisation that +their environment requires the most delicate adjustment, and when +matters have gone wrong, it may be very difficult to restore health of +mind and body. When a peculiarly nervous temperament is inherited, +wisdom in the management of the child is essential, and may sometimes +achieve the happiest results. Heredity is so powerful a factor in the +development of the nervous organisation of the child that, realising +its importance, we should be sparing in our criticism of the results +which the mothers who consult us achieve in the training of their +children. A sensitive, nervous organisation is often the mark of +intellectual possibilities above the average, and the children who are +cast outside the ordinary mould, who are the most wayward, the most +intractable, who react to trifling faults of management with the most +striking symptoms of disturbance, are often those with the greatest +potentialities for achievement and for good. It is natural for the +mother of placid, contented, and perhaps rather unenterprising +children, looking on as a detached outsider, seeing nothing of the +teeming activities of the quick, restless little brain, and the +persistent, though faulty reasoning--it is natural for her to blame +another's work, and to flatter herself that her own routine would have +avoided all these troublesome complications. The mother of the nervous +child may often rightly take comfort in the thought that her child is +worth the extra trouble and the extra care which he demands, because +he is sent into the world with mechanism which, just because it is +more powerful than the common run, is more difficult to master and +takes longer to control and to apply for useful ends. + +It is through the mother, and by means of her alone, that the doctor +can influence the conduct of the child. Without her co-operation, or +if she fails to appreciate the whole situation, with the best will in +the world, we are powerless to help. Fortunately with the majority of +educated mothers there is no difficulty. Their powers of observation +in all matters concerning their children are usually very great. It is +their interpretation of what they have observed that is often faulty. +Thus, in the example given above, the mother observes correctly that +defaecation is inhibited, and produces crying and resistance. It is +her interpretation that the cause is to be found in pain that is at +fault. Again, a mother may bring her infant for tongue-tie. She has +observed correctly that the child is unable to sustain the suction +necessary for efficient lactation, and has hit upon this fanciful and +traditional explanation. The doctor, who knows that the tongue takes +no part in the act of sucking, will probably be able to demonstrate +that the failure to suck is due to nasal obstruction, and that the +child is forced to let go the nipple because respiration is impeded. +The opportunities for close observation of the child which mothers +enjoy are so great that we shall not often be justified in +disregarding their statements. But if we are able to give the true +explanation of the symptoms, it will seldom happen that the mother +will fail to be convinced, because the explanation, if true, will fit +accurately with all that has been observed. Thus the mother of the +child in whom defaecation is inhibited by negativism may have made +further observations. For example, she may have noted that the +so-called constipation causes fretfulness, that it is almost always +benefited by a visit to the country or seaside, or that it has become +much worse since a new nurse, who is much distressed by it, has taken +over the management of the child. To this mother the explanation must +be extended to fit these observations, of the accuracy of which there +need be no doubt. Fretfulness and negativism with all children whose +management is at fault come in waves and cycles. The child, naughty +and almost unmanageable one week, may behave as a model of propriety +the next. The negativism and refusal to go to stool are the outcome of +the nervous unrest, not its cause. Again, the nervous child, like the +adult neuropath, very often improves for the time being with every +change of scene and surroundings. It is the _ennui_ and monotony of +daily existence, in contact with the same restricted circle, that +becomes insupportable and brings into prominence the lack of moral +discipline, the fretfulness, and spirit of opposition. Lastly, the +conduct of the nervous child is determined to a great extent by +suggestions derived from the grown-up people around him. Refusal of +food, refusal of sleep, refusal to go to stool, as we shall see later, +only become frequent or habitual when the child's conduct visibly +distresses the nurse or mother, and when the child fully appreciates +the stir which he is creating. The mother will readily understand that +in such a case, where constipation varies in degree according as +different persons take charge of the child, the explanation offered is +that which alone fits with the observed facts. A full and free +discussion between mother and doctor, repeated it may be more than +once, may be necessary before the truth is arrived at, and a line of +action decided upon. Only so can the doctor, remote as he is from the +environment of the child, intervene to mould its nature and shape its +conduct. + +If the doctor is to fit himself to give advice of this sort, he must +be a close observer of little children. He must not consider it +beneath his dignity to study nursery life and nursery ways. There he +will find the very beginnings of things, the growing point, as it +were, of all neuropathy. A man of fifty, who in many other ways showed +evidence of a highly nervous temperament, had especially one +well-marked phobia, the fear of falling downstairs. It had never been +absent all his life, and he had grown used to making the descent of +the stairs clinging firmly to the stair-rail. Family tradition +assigned this infirmity to a fall downstairs in early childhood. But +all children fall downstairs and are none the worse. The persistence +of the fear was due, I make no doubt, to the attitude of the parents +or nurse, who made much of the accident, impressed the occasion +strongly on the child's memory, and surrounded him thereafter with +precautions which sapped his confidence and fanned his fears. + +In what follows we will consider first the subject of nursery +management, searching in it for the origin of the common disorders of +conduct both of childhood and of later life. I have grouped these +nursery observations under the heads of four characteristic features +of the child's psychology--his Imitativeness, his Suggestibility, his +Love of Power, and his acute though limited Reasoning Faculties. I +feel that some such brief examination is necessary if we are to +understand correctly the aetiology of some of the most troublesome +disorders of childhood, such as enuresis, anorexia, dyspepsia, or +constipation, disorders in which the nervous element is perhaps to-day +not sufficiently emphasised. Finally, we can evolve a kind of nursery +psycho-therapeutics--a subject which is not only of fascinating +interest in itself, but which repays consideration by the success +which it brings to our efforts to cure and control. + + + + +CHAPTER II + +OBSERVATIONS IN THE NURSERY + + +_(a)_ THE IMITATIVENESS OF THE CHILD + +It is in the second and third years of the child's life that the +rapidity of the development of the mental processes is most apparent, +and it is with that age that we may begin a closer examination. At +first sight it might seem more reasonable to adopt a strictly +chronological order, and to start with the infant from the day of his +birth. Since, however, we can only interpret the mind of the child by +our knowledge of our own mental processes, the study of the older +child and of the later stages is in reality the simpler task. The +younger the infant, the greater the difficulties become, so that our +task is not so much to trace the development of a process from simple +and early forms to those which are later and more complex, as to +follow a track which is comparatively plain in later childhood, but +grows faint as the beginnings of life are approached. + +At the age, then, of two or three the first quality of the child which +may arrest our attention is his extreme imitativeness. Not that the +imitation on his part is in any way conscious; but like a mirror he +reflects in every action and in every word all that he sees and hears +going on around him. We must recognise that in these early days his +words and actions are not an independent growth, with roots in his own +consciousness, but are often only the reflection of the words and +actions of others. How completely speech is imitative is shown by the +readiness with which a child contracts the local accent of his +birthplace. The London parents awake with horror to find their baby an +indubitable Cockney; the speech of the child bred beyond the Tweed +proclaims him a veritable Scot. Again, some people are apt to adopt a +somewhat peremptory tone in addressing little children. Often they do +not trouble to give to their voices that polite or deferential +inflection which they habitually use when speaking to older people. +Listen to a party of nurses in the Park addressing their charges. As +if they knew that their commands have small chance of being obeyed, +they shout them with incisive force. "Come along at once when I tell +you," they say. And the child faithfully reflects it all back, and is +heard ordering his little sister about like a drill sergeant, or +curtly bidding his grandmother change her seat to suit his pleasure. +If we are to have pretty phrases and tones of voice, mothers must see +to it that the child habitually hears no other. Again, mothers will +complain that their child is deaf, or, at any rate, that he has the +bad habit of responding to all remarks addressed to him by saying, +"What?" or, worse still, "Eh?" Often enough the reason that he does so +is not that the child is deaf, nor that he is particularly slow to +understand, but simply that he himself speaks so indistinctly that no +matter what he says to the grown-up people around him, they bend over +him and themselves utter the objectionable word. + +We all hate the tell-tale child, and when a boy comes in from his walk +and has much to say of the wicked behaviour of his little sister on +the afternoon's outing, his mother is apt to see in this a most horrid +tendency towards tale-bearing and currying of favour. She does not +realise that day by day, when the children have come in from their +walk, she has asked nurse in their hearing if they have been good +children; and when, as often happens, they have not, the nurse has +duly recounted their shortcomings, with the laudable notion of putting +them to shame, and of emphasising to them the wickedness of their +backsliding--and this son of hers is no hypocrite, but speaks only, as +all children speak, in faithful reproduction of all that he hears. +Those grown-up persons who are in charge of the children must realise +that the child's vocabulary is their vocabulary, not his own. It is +unfortunate, but I think not unavoidable, that so often almost the +earliest words that the infant learns to speak are words of reproof, +or chiding, or repression. The baby scolds himself with gusto, +uttering reproof in the very tone of his elders: "No, no," "Naughty," +or "Dirty," or "Baby shocked." + +Speech, then, is imitative from the first, if we except the early baby +sounds with reduplication of consonants to which in course of time +definite meaning becomes attached, as "Ba-ba," "Ma-ma," "Na-na," +"Ta-ta," and so forth. Action only becomes imitative at a somewhat +later stage. The first purposive movements of the child's limbs are +carried out in order to evoke tactile sensations. He delights to +stimulate and develop the sense of touch. At first he has no knowledge +of distance, and his reach exceeds his grasp. He will strain to touch +and hold distant objects. Gradually he learns the limitations of +space, and will pick up and hold an object in his hand with precision. +Often he conveys everything to his mouth, not because his teeth are +worrying him, or because he is hungry, as we hear sometimes alleged, +but because his mouth, lips, and tongue are more sensitive, because +more plentifully furnished with the nerves of tactile sensation. By +constant practice the sense of touch and the precision of the movement +of his hands are slowly developed, and not these alone, for the child +in acquiring these powers has developed also the centres in the brain +which control the voluntary movements. When the child can walk he +continues these grasping and touching exercises in a wider sphere. As +the child of fifteen or eighteen months moves about the room, no +object within his reach is passed by. He stretches out his hand to +touch and seize upon everything, and to experience the joy of +imparting motion to it. The impulse to develop tactile sensation and +precision in the movements of his hands compels him with irresistible +force. It is foolish to attempt to repress it. It is foolish, because +it is a necessary phase in his development, and moreover a passing +phase. No doubt it is annoying to his elders while it lasts, but the +only wise course is to try to thwart as little as we can his +legitimate desire to hold and grasp the objects, and even to assist +him in every way possible. But the mother must assist him only by +allowing free play to his attempts. To hand him the object is to +deprive the exercise of most of its value. Incidentally she may teach +him the virtue of putting things back in their proper places, an +accomplishment in which he will soon grow to take a proper pride. If +she attempts continually to turn him from his purpose, reproving him +and snatching things from him, she prolongs the grasping phase beyond +its usual limits. And she does a worse thing at the same time. Lest +the quicker hands of his nurse should intervene to snatch the prize +away before he has grasped it, he too learns to snatch, with a sudden +clumsy movement that overturns, or breaks, or spills. If left to +himself he will soon acquire the dexterity he desires. He may overturn +objects at first, or let them fall, but this he regards as failure, +which he soon overcomes. A child of twenty months, whose development +in this particular way has not been impeded by unwise repression, will +pick out the object on which he has set his heart, play with it, +finger it, and replace it, and he will do it deliberately and +carefully, with a clear desire to avoid mishap. Dr. Montessori, who +has developed into a system the art of teaching young children to +learn precision of movement and to develop the nerve centres which +control movement, tells in her book a story which well illustrates +this point.[1] + +[Footnote 1: _The Montessori Method_, pp. 84, 85.] + +"The directress of the Casa del Bambini at Milan constructed under one +of the windows a long, narrow shelf, upon which she placed the little +tables containing the metal geometric forms used in the first lesson +in design. But the shelf was too narrow, and it often happened that +the children in selecting the pieces which they wished to use would +allow one of the little tables to fall to the floor, thus upsetting +with great noise all the metal pieces which it held. The directress +intended to have the shelf changed, but the carpenter was slow in +coming, and while waiting for him she discovered that the children had +learned to handle these materials so carefully that in spite of the +narrow and sloping shelf, the little tables no longer fell to the +ground. The children, by carefully directing their movements, had +overcome the defect in this piece of furniture." + +By slow degrees the child learns to command his movements. If his +efforts are aided and not thwarted, before he is two years old he will +have become capable of conducting himself correctly, yet with perfect +freedom. The worst result of the continual repression which may be +constantly practised in the mistaken belief that the grasping phase is +a bad habit which persistent opposition will eradicate, is the nervous +unrest and irritation which it produces in the child. A passionate fit +of crying is too often the result of the thwarting of his nature, and +the same process repeated over and over again, day by day, almost hour +by hour, is apt to leave its mark in unsatisfied longing, +irritability, and unrest. Above all, the child requires liberty of +action. + +We have here an admirable example of the effect of environment in +developing the child's powers. A caged animal is a creature deprived +of the stimulus of environment, and bereft therefore to a great extent +of the skill which we call instinct, by which it procures its food, +guarantees its safety from attack, constructs its home, cares for its +young, and procreates its species. If, metaphorically speaking, we +encircle the child with a cage, if we constantly intervene to +interpose something between him and the stimulus of his environment, +his characteristic powers are kept in abeyance or retarded, just as +the marvellous instinct of the wild animals becomes less efficient in +captivity. + +The grasping phase is but a preliminary to more complex activities. +Just as in schooldays we were taught with much labour to make +pot-hooks and hangers efficiently before we were promoted to real +attempts at writing, so before the child can really perform tasks with +a definite meaning and purpose, he must learn to control the finer +movements of his hands. Once the grasping phase, the stage of +pot-hooks, is successfully past--and the end of the second year in a +well-managed child should see its close--the child sets himself with +enthusiasm to wider tasks. To him washing and dressing, fetching his +shoes and buttoning his gaiters, all the processes of his simple +little life, should be matters of the most enthralling interest, in +which he is eager to take his part and increasingly capable of doing +so. In the Montessori system there is provided an elaborate apparatus, +the didactic material, designed to cultivate tactile sensation and the +perception of sense stimuli. It will generally suffice to advise the +mother to make use of the ordinary apparatus of the nursery. The +imitativeness of the young child is so great that he will repeat in +almost every detail all the actions of his nurse as she carries out +the daily routine. At eighteen months of age, when the electric light +is turned on in his nursery, the child will at once go to the curtains +and make attempts to draw them. At the same age a little girl will +weigh her doll in her own weighing-machine, will take every precaution +that the nurse takes in her own case, and will even stoop down +anxiously to peer at the dial, just as she has seen her mother and +nurse do on the weekly weighing night. But at a very early age +children appreciate the difference between the real and the +make-believe. They desire above all things to do acts of real service. +At the age of two a child should know where every article for the +nursery table is kept. He will fetch the tablecloth and help to put it +in place, spoons and cups and saucers will be carried carefully to the +table, and when the meal is over he will want to help to clear it all +away. All this is to him a great delight, and the good nurse will +encourage it in the children, because she sees that in doing so they +gain quickness and dexterity and poise of body. The first purposive +movements of the child should be welcomed and encouraged. It is +foolish and wrong to repress them, as many nurses do, because the +child in his attempts gets in the way, and no doubt for a time delays +rather than expedites preparations. The child who is made to sit +immobile in his chair while everything is done for him is losing +precious hours of learning and of practice. It is useless, and to my +mind a little distasteful, to substitute for all this wonderful child +activity the artificial symbolism of the kindergarten school in which +children are taught to sing songs or go through certain semi-dramatic +activities which savour too much of a performance acquired by precise +instruction. If such accomplishments are desired, they may be added +to, but they must not replace, the more workaday activities of the +little child. The child whose impulses towards purposive action are +encouraged is generally a happy child, with a mind at rest. When those +impulses are restrained, mental unrest and irritability are apt to +appear, and toys and picture books and kindergarten games will not be +sufficient to restore his natural peace of mind. + + +_(b)_ THE SUGGESTIBILITY OF THE CHILD + +We may pass from considering the imitativeness of the child to study a +second and closely related quality, his suggestibility. His conception +of himself as a separate individual, of his ego, only gradually +emerges. It is profoundly modified by ideas derived from those around +him. Because of his lack of acquired experience, there is in the child +an extreme sensitiveness to impressions from outside. Take, for +example, a matter that is sometimes one of great difficulty, the +child's likes and dislikes for food. Many mothers make complaint that +there are innumerable articles of diet which the child will not take: +that he will not drink milk, or that he will not eat fat, or meat, or +vegetables, or milk puddings. There are people who believe that these +peculiarities of taste correspond with idiosyncrasies of digestion, +and that children instinctively turn from what would do them harm. I +do not believe that there is much truth in this contention. If we +watch an infant after weaning, at the time when his diet is gradually +being enlarged to include more solid food, with new and varied +flavours, we may see his attention arrested by the strange sensations. +With solid or crisp food there may be a good deal of hesitation and +fumbling before he sets himself to masticate and swallow. With the +unaccustomed flavour of gravy or fruit juice there may be seen on his +face a look of hesitation or surprise. In the stolid and placid child +these manifestations are as a rule but little marked, and pleasurable +sensations clearly predominate. With children of more nervous +temperament it is clear that sensations of taste are much more acute. +Even in earliest infancy, children have a way of proclaiming their +nervous inheritance by the repugnance which they show to even trifling +changes in the taste or composition of their food. We see the same +sensitiveness in their behaviour to medicines. The mixture which one +child will swallow without resentment, and almost eagerly, provokes +every expression of disgust from another, or is even vomited at once. +In piloting the child through this phase, during which he starts +nervously at all unaccustomed sensations and flavours, the attitude of +mother and nurse is of supreme importance. It is unwise to attempt +force; it is equally unwise, by excessive coaxing, cajoling, and +entreaty, to concentrate the child's attention on the matter. If +either is tried every meal is apt to become a signal for struggling +and tears. The phase, whether it is short or long continued, must be +accepted as in the natural order of things, and patience will see its +end. The management of this symptom,--refusal of food and an +apparently complete absence of desire for food,--which is almost the +commonest neurosis of childhood, will be dealt with later. Here it is +mentioned because I wish to emphasise that if too much is made of a +passing hesitation over any one article of food, if it becomes the +belief of the mother or nurse that a strong distaste is present, then +if she is not careful her attitude in offering it, because she is +apprehensive of refusal, will exert a powerful suggestion on the +child's mind. Still worse, it may cause words to be used in the +child's hearing referring to this peculiarity of his. By frequent +repetition it becomes fixed in his mind that this is part of his own +individuality. He sees himself--and takes great pleasure in the +thought--as a strange child, who by these peculiarities creates +considerable interest in the minds of the grown-up people around him. +When the suggestion takes root it becomes fixed, and as likely as not +it will persist for his lifetime. It may be habitually said of a child +that, unlike his brothers and sisters, he will never eat bananas, and +thereafter till the day of his death he may feel it almost a physical +impossibility to gulp down a morsel of the offending fruit. So, too, +there are people who can bolt their food with the best of us, who yet +declare themselves incapable of swallowing a pill. + +Another example of the force of suggestion, whether unconscious or +openly exercised by speech, is given us in the matter of sleep. Among +adults the act of going to bed serves as a powerful suggestion to +induce sleep. Seldom do we seek rest so tired physically that we drop +off to sleep from the irresistible force of sheer exhaustion. Yet as +soon as the healthy man whose mind is at peace, whose nerves are not +on edge, finds himself in bed, his eyes close almost with the force of +a hypnotic suggestion, and he drops off to sleep. With some of us the +suggestion is only powerful in our own bed, that on which it has acted +on unnumbered nights. We cannot, as we say, sleep in a strange bed. It +is suggestion, not direct will power, that acts. No one can absolutely +will himself to sleep. In insomnia it is the attempt to replace the +unconscious auto-suggestion by a conscious voluntary effort of will +that causes the difficulty. A thousand times in the night we resolve +that now we _will_ sleep. If we could but cease to make these +fruitless efforts, sleep might come of itself and the suggestion or +habit be re-established. + +In little children the suggestion of sleep, provoked by being placed +in bed, sometimes acts very irregularly. Often it may succeed for a +week or two, and then some untoward happening breaks the habit, and +night after night, for a long time, sleep is refused. The wakeful +child put to bed, resents the process, and cries and sobs miserably, +to the infinite distress of his mother. It then becomes just as likely +that the child will connect his bed in his mind, not with rest and +sleep, but with sobbing and crying on his part, and mingled entreaties +and scoldings from his nurse or mother. An important part in this +perversion of the suggestion is played by the attitude of the person +who puts the child to bed. Often the nurse is uniformly successful, +while the mother, who is perhaps more distressed by the sobbing of the +child, as consistently fails, because she has been unable to hide her +apprehension from him, and has conveyed to his mind a sense of his own +power. + +Just in the same way, grown-up people, filled with anxiety because of +the helplessness of the young child, unable to divest their minds of +the fears of the hundred and one accidents that may befall, or that +within their own experience have befallen, a little child at one time +or another, unconsciously make unwise suggestions which fill his mind +with apprehension and terror. They do not like their children to show +fear of animals. Nor would they if it were not that their own +apprehension that the child may be hurt communicates itself to him. +The child is not of himself afraid to fall, it is they who suffer the +anxiety and show it by treating the fall as a disaster. The child is +not of himself afraid to be left alone in a room. It is they who sap +his confidence in himself, because they do not venture to leave him +out of their sight, from a nameless dread of what may happen. A little +girl cut her finger and ran to her nurse, pleased and interested: +"See," she said, seeing it bleed, "fingers all jammy." Only when the +nurse grasped her with unwise expressions of horror did she break into +cries of fear. A town-bred nurse, who is afraid of cows, will make +every country walk an ordeal of fear for the children. + +Every mother must be made to realise the ease with which these +unconscious suggestions act upon the mind of the little child, and +should school herself to be strong to make her child strong, and to +see to it that all this suggestive force is utilised for good and not +for evil. + +It is upon this susceptibility to suggestion that a great part of his +early education reposes. No one who is incapable of profiting by this +natural disposition of the child can be successful in her management +of him. Turn where you will in his daily life the influence of this +force of suggestion is clearly apparent. The child does without +questioning that which he is confidently expected to do. Thus he will +eat what is given him, and sleep soundly when he is put to bed if only +the appropriate suggestion and not the contrary is made to him. Again +we have seen that a perversion of suggestion of this sort is a common +source of constipation in early childhood. If the child's attention is +directed towards the difficulty, if he is urged or ordered or appealed +to to perform his part, if failure is looked upon as a serious +misfortune, the bowels may remain obstinately unmoved. In children as +in adults a too great concentration of attention inhibits the action +of the bowels, and constipation, in many persons, is due to the +attempt to substitute will power for the force of habitual suggestion. +No matter what other treatment we adopt, the mother must be careful to +hide from the child that his failure is distressing to her. A cheerful +optimism which teaches him to regard himself as one who is +conspicuously regular in his habits, and who has a reputation in this +respect to live up to is sure to succeed. To talk before him of his +habitual constipation, and to worry over the difficulty, is as surely +to fail. In the same way unwise suggestion can interfere with the +passing of water at regular and suitable intervals. There are children +who constantly desire to pass water on any occasion, which is +conspicuously inappropriate, because their attention has been +concentrated on the sensations in the bladder. Often enough when at +great inconvenience opportunity has been found, the desire has passed +away, and all the trouble has proved needless. It is not too much to +say that every occupation and every action of the day can be made +delightful or hateful to the child, according to the suggestion with +which it is presented and introduced. Dressing and undressing, eating +and drinking, bathing, washing, the putting away of toys, even going +to bed, can be made matters of enthralling interest or delight, or a +subject for tears and opposition, according to the bias which is given +to the child's mind by the words, attitude, and actions of nurses and +mothers. + +Here we approach very near to the heart of the subject. Stripped of +all that is not essential we see the problem of the management of +children reduced to the interplay between the adult mind and the mind +of the receptive suggestible child. That which is thought of and +feared for the child, that he rapidly becomes. Placid, comfortable +people who do not worry about their children find their children +sensible and easy to manage. Parents who take a pride in the daring +and naughty pranks of their children unconsciously convey the +suggestion to their minds that such conduct is characteristic of them. +Nervous and apprehensive parents who are distressed when the child +refuses to eat or to sleep, and who worry all day long over possible +sources of danger to him, are forced to watch their child acquire a +reputation for nervousness, which, as always, is passively accepted +and consistently acted up to. Differences in type, determined by +hereditary factors, no doubt, exist and are often strongly marked. Yet +it is not untrue to say that variations in children, dependent upon +heredity, show chiefly in the relative susceptibility or +insusceptibility of the child to the influences of environment and +management. It is no easy task to distinguish between the nervous +child and the child of the nervous mother, between the child who +inherits an unusually sensitive nervous system and the child who is +nervous only because he breathes constantly an atmosphere charged with +doubt and anxiety. + + +(_c_) THE CHILD'S LOVE OF POWER + +Let us study briefly a third quality of the child which, for want of a +better name, I have called after the ruling passion of mankind, his +love of power. Perhaps it would be better to call it his love of being +in the centre of the picture. It is his constant desire to make his +environment revolve around him and to attract all attention to +himself. Somewhat later in life this desire to attract attention, at +all costs, is well seen in the type of girl popularly regarded as +hysterical. The impulse is then a morbid and debased impulse; in the +child it is natural and, within limits, praiseworthy. A girl of this +sort, who feels that she is not likely to attract attention because of +any special gifts of beauty or intellect which she may possess, +becomes conscious that she can always arouse interest by the severity +of her bodily sufferings. The suggestion acts upon her unstable mind, +and forthwith she becomes paralysed, or a cripple, or dumb, presenting +a mimicry or travesty of some bodily ailment with which she is more or +less familiar. "Hysterical" girls will even apply caustic to the skin +in order to produce some strange eruption which, while it sorely +puzzles us doctors, will excite widespread interest and commiseration. +Now little children will seldom carry their desire to attract +attention so far as to work upon the feelings of their parents by +simulating disease. They have not the necessary knowledge to play the +part, and even if they make the attempt, complaining of this or that +symptom which they notice has aroused the interest of their elders, +the simulation is not likely to be so successful as to deceive even a +superficial observer. But within the limits of their own powers, +children are past masters in attracting attention. The little child is +unable to take part in any sustained conversation; most of his +talking, indeed, is done when he is alone, and is addressed to no one +in particular. But he knows well that by a given action he can produce +a given reaction in his mother and nurse. A great part of what is said +to him--too great a part by far--comes under the category of reproof +or repression. He is forbidden to do this or that, coaxed, cajoled, +threatened long before he is old enough to understand the meaning of +the words spoken, although he knows the tone in which they are uttered +and loves to produce it at will. How he enjoys it all! Watch him draw +near the fire, the one place that is forbidden him. He does not mean +to do himself harm. He knows that it is hot and would hurt him, but +for the time being he is out of the picture and he is intent on +producing the expected response, the reproof tone from his mother +which he knows so well. He approaches it warily, often anticipating +his mother's part and vigorously scolding himself. He desires nothing +more than that his mother should repeat the reproof, forbidding him a +dozen times. The mind of all little children tends easily to work in a +groove. It delights in repetition and it evoking not the unexpected +but the expected. If his sport is stopped by his mother losing +patience and removing him bodily from the danger zone, his sense of +impotence finds vent in passionate crying. But if his mother takes no +notice, the sport soon loses its savour. He is conscious that somehow +or other it has fallen flat, and he flits off to other employment. + +Mothers will complain that children seem to take a perverse pleasure +in evoking reproof, appeals, entreaties, and exhortations. A small boy +of four who had several times repeated the particular sin to which his +attention had been directed by the frequency of his mother's warnings +and entreaties, finding that on this occasion she had decided to take +no notice, approached her with a troubled face: "Are you not angry?" +he said; "are you not disappointed?" In reality the naughty child is +often only the child who has become master of his mother's or his +nurse's responses, and can produce at will the effect he desires. The +idea that the child possesses a strong will, which can and must be +broken by persistent opposition, is based upon this tendency of the +child. It is an entire misconception of the situation: Strength of +will and fixity of purpose are among the last powers which the human +mind develops. In little children they are conspicuously absent. What +appears to us as a fixed and persistent desire to perform a definite +action in spite of all we can say or do, is often no more than the +desire to produce the familiar tones of reproof, to traverse again the +familiar ground, to attract attention and to find himself again the +centre of the picture. If no one pays any attention and no one +reproves, he soon gives up the attempt. If too much is made of any one +action of the child, a strong impression is made on his mind and he +cannot choose but return to it again and again. + +This little drama of the fireplace may teach us a great deal in the +management of children. The wise mother and nurse will find a hundred +devices to catch the child's attention and lure him away from the +danger zone without the incident making any impression on his mind at +all, and will not call attention to it by repeated reproofs or +warnings which will certainly lead him straight back to the spot. + +In matters of greater moment the same impulse to oppose the will of +those around him is seen. In considering the point of the child's +susceptibility to suggestion, we have mentioned the refusal of sleep +and the refusal of food. In both it is possible to detect the +influence of this pronounced force of opposition. As the child lies +sobbing or screaming in bed, every new approach to him, every fresh +attempt at pacification, renews the force of his opposition in a +crescendo of sound. But it is in his refusal of food that the child is +apt to find his chief opportunity. Meal-times degenerate into a +struggle. There at least he can show his complete mastery of the +situation. No one can swallow his food for him, and he knows it. He +can clench his teeth and shake his head and obstinately refuse every +morsel offered. He can hold food in his mouth for half an hour at a +time and remain deaf to all the appeals of his helpless nurse. If she +tries force, he quells the attempt by a storm of crying. If she +declines upon entreaty and coaxing, he will not be persuaded. It is +the little scene of the fireplace over again. The attempts at force or +the attempts at persuasion, by making much of it, have concentrated +the attention of the child upon the difficulty, and have taught him +his own power to dominate the situation. + +It is right that parents should realise that the disturbing and +irritating element in the child's environment is nearly always +provided by the intrusion of the adult mind and its contact with the +child's. Some supervision and some intrusion, therefore, is of course +absolutely necessary, but the best-regulated nursery is that in which +it is least evident. Something is definitely wrong if a child of two +years will not play for half an hour at a time happily and busily in a +room by himself. It is an even better test if the child will play +amicably by himself with nurse or mother in the room, without the two +parties crossing swords on a single occasion, without reproof or +repression on the one side or undue attempts to attract attention on +the other. If the child is entirely dependent upon the participation +of grown-up persons in his pursuits, then not only do those pursuits +lose much of their educative force, but they become a positive source +of danger because of the constant interplay of personality with +personality. The child who, seated on the ground, will play with his +toys by himself, rises with a brain that is stimulated but not +exhausted. Only very rarely do we find that solitary play, or play +between children, is too exciting. In older children of very quick +intelligence and nervous temperament we occasionally find that the +pace which they themselves set is too exciting or exhausting. I recall +a little boy of seven, an only child of particularly wise and +thoughtful parents, who was brought to me with the complaint that he +exhausted himself utterly both in body and mind by the intense nervous +energy which he threw into his pursuits. For instance, he had been +interested in the maps illustrating the various fronts in the European +War, with which the walls of his father's study were hung, and +although left entirely by himself he had become intensely excited and +exhausted by the eagerness with which he had spent a whole morning, +with a wealth of imaginative force, in drawing a map of the garden of +his house and converting it into the likeness of a war map, filled +with imaginary Army Corps. Such excessive expenditure of nervous force +is unusual even in older children, and as in this case is found +usually only when there is a pronounced nervous inheritance. In little +children in the nursery, solitary play or play between themselves +seldom produces nervous exhaustion. It is quite otherwise when the +child is dependent to a too great extent upon the participation of +adults. It is almost impossible for the mother and nurse not to take +the leading part in the exchange of ideas, and no matter what may be +their good intentions, the pace set is apt to be too great. +Environment, without the intrusion of the adult mind, is best able to +adjust the necessary stimulus and produce development without +exhaustion. Play with grown-up persons, the reading aloud of story +books, the showing of pictures, and so forth, undoubtedly have their +own importance, but they should be confined within strict limits and +to a definite hour in the daily routine. There is sometimes too great +a tendency for parents to make playthings of their little children. +Save at stated times, they must curb their desire to join in their +games, to gather them in their arms, to hold them on their knee, while +they stimulate their minds by a constant succession of new +impressions. With an only child, whose existence is the single +preoccupation of the nurse and mother, and, often enough, of the +father as well, it is difficult to avoid this fault. Yet, if wisdom is +not learnt, the damage to the child may be distressingly serious. He +rapidly grows incapable of supporting life without this excessive +stimulation. Without the constant society and attention of a grown +person, he feels himself lost. He cannot be left alone, and yet cannot +enjoy the society he craves. He grows more and more restless, +dominating the whole situation more and more, constantly plucking at +his nurse's skirts, perversely refusing every new sensation that is +offered him to still his restlessness for a moment. The result of all +this stimulation is mental irritability and exhaustion, which in turn +is often the direct cause of refusal of food, dyspepsia, wakefulness, +and excessive crying. + +The devices by which children will attract to themselves the +attention of their elders, and which, if successful, are repeated with +an almost insane persistence, take on the most varied forms. Sometimes +the child persistently makes use of an expression, or asks questions, +which produce a pleasant stir of shocked surprise and renewed reproofs +and expostulations. One little boy shouted the word "stomachs" with +unwearied persistence for many weeks together. A little girl dismayed +her parents and continued in spite of all they could do to prevent her +to ask every one if they were about to pass water. + +Disorders of conduct of this sort are not really difficult to control. +Suitable punishment will succeed, provided also that the child is +deprived of the sense of satisfaction which he has in the interest +which his conduct excites. His behaviour is only of importance because +it indicates certain faults in his environment and a certain element +of nervous unrest and overstrain. + +The young child demands from his environment that it should give him +two things--security and liberty. He must have security from shocks to +his nervous system. It is true that from the greater shocks the +children of the well-to-do are as a rule carefully guarded. No one +threatens or ill-uses them. They are not terrified by drunken brawls +or scenes of passion. They are not made fearful by the superstitions +of ignorant people. Nevertheless, by the summation of stimuli little +emotions constantly repeated can have effects no less grave upon +their nervous system. From this constantly acting irritation the child +needs security. In the second place, he requires liberty to develop +his own initiative, which should be stimulated and sustained and +directed. Without liberty and without security conduct cannot fail to +become abnormal. + + +(_d_) THE REASONING POWER OF THE CHILD + +Before we proceed to a closer examination of the various symptoms of +nervous unrest in detail, we may very briefly consider the scope and +power of the child's understanding. As a rule I am sure that it is +grossly underestimated. The mental processes of the child are far +ahead of his power of speech. The capacity for understanding speech is +well advanced, and an appeal to reason is often successful while the +child is still powerless to express his own thoughts in words. Because +he cannot so express himself there is a tendency to underestimate the +acuteness of his reasoning, to talk down to him, and to imagine that +he can be imposed upon by any fiction which seems likely to suit the +purpose of the moment. A child of eighteen months is not too young to +be talked to in a quiet, straightforward, sensible way. Only if he is +treated as a reasonable being can we expect his reasoning faculties to +develop. Children dislike intensely the unexplained intervention of +force. If a pair of scissors, left by an oversight lying about, has +been grasped, the first impulse of the mother is to snatch the danger +hurriedly from the child's hands, and her action will generally be +followed by resistance and a storm of weeping. She will do better to +approach him quietly, telling him that scissors hurt babies, and show +him where to place them out of harm's way. Watch a child at play after +his midday meal. He has been out in his perambulator half the morning, +and for the other half has been deep in his midday sleep. Now that +dinner is over he is for a moment master of his time and busily +engaged in some pursuit dear to his heart. At two o'clock inexorable +routine ordains that he must again be placed in the perambulator and +wheeled forth on a fresh expedition. If the nurse does not know her +business she will swoop down upon him, place him on her knee, and +begin to envelop his struggling little body in his outdoor clothes, +scolding his naughtiness as he kicks and screams. If she has a way +with children she will open the cupboard door and call on him to help +find his gaiters and his shoes because it is time for his walk. In a +moment he will leave his toys, forgetting all about them in the joy of +this new activity. + +If the reason for things is explained to children they grow quick to +understand quite complicated explanations. A little girl, not yet two, +was playing with her Noah's Ark on the dining-room table with its +polished surface. The mother interposed a cloth, explaining that the +animals would scratch the table if the cloth were not there. Within a +few minutes the child twice lifted the cloth, peering under it and +saying, "Not scratch table." Yet how often do we find +facetiously-minded persons confound their reasoning and confuse their +judgment by foolish speeches and cock-and-bull tales, which, just +because of their foolishness, seem to them well adapted to the infant +intelligence. + +An attempt to deceive the child is almost always wrong, and because of +our tendency to underestimate the child's intelligence it generally +fails. If a little girl has a sore throat, and the doctor comes to see +her, she knows quite well that she is the prospective patient. It is +useless for the mother to begin proceedings by trying to convince her +that this is not so--that mother has a sore throat too. Such a plan +only arouses apprehension, because the child scents danger in the +artifice. + +Closely connected with the reasoning powers of the child is the +difficult question of the growth of his appreciation of right and +wrong, or, to put it in another way, the growth of obedience or +disobedience. Sooner or later the child must learn to obey; on that +there can be no two opinions. Nevertheless, I think there can be no +doubt that far more harm is done by an over-emphasis of authority than +by its neglect. If the nurse or mother is of strong character, and the +authority is exercised persistently and remorselessly, so that the +whole life of the child is dominated, much as the recruit's existence +in the barrack yard is dominated by the drill sergeant, his +independence of nature is crushed. He is certain to become a +colourless and uninteresting child; he runs a grave risk of growing +sly, broken-spirited, and a currier of favour. If a child is +ruthlessly punished for disobedience from his earliest years, there +is, it need hardly be said, a grave risk that he will learn to lie to +save his skin. I have seen a few such cases of what I may call the +remorseless exercise of authority, and the result has not been +pleasing. Fortunately, perhaps, not many women have the heart to adopt +this attitude to the waywardness of little children--a waywardness to +which their whole nature compels them by their pressing need to +cultivate tactile sensations, to experiment, and to explore. +Therefore, much more commonly, the authority is exercised +intermittently and capriciously, with the result that the child's +judgment is clouded and confused. Conduct which is received +indulgently or even encouraged at one moment is sternly reprimanded at +another. Every one who has the management of little children must +above all see to it, whatever the degree of stringency in discipline +which they decide to adopt, that their attitude is always consistent. +The less that is forbidden the better, but when the line is drawn it +must be adhered to. If once the child learns that the force which +restrains him can be made to yield to his own efforts, the future is +black indeed. From that day he sets himself to strike down authority +with a success which encourages him to further efforts. I have known a +child of five years terrorise his mother and get his own way by the +threat, "I will go into one of my furies." + +The difficulty of successfully enforcing authority, and of carrying +off the victory if that authority is disputed, should make mothers +wary of drawing too tight a rein. The conflict between parent and +child must always be distressing and must always be prejudicial to the +child, whatever its outcome, whether it brings to him victory or +defeat. He learns from it either an undue sense of power or an undue +sense of helplessness, and the knowledge of neither is to his benefit. +Although frequently worsted in the conflict, nurses will often return +to the attack again and again and hour after hour, restraining, +reproving, forbidding, and even threatening. Nor do they see that they +are really goading the children into disobedience by their misdirected +efforts at enforcing discipline. Reproof, like punishment, loses all +its effect when it is too often repeated, and the child soon takes it +for granted that all he does is wrong, and that grown-up people exist +only to thwart his will, to misunderstand, to reprove, or even to +punish. + +In the nursery the word "naughty" is far too frequently heard. It is +naughty to do this, it is naughty to do that. There is no gradation in +the condemnation, and the child loses all sense of the meaning of the +word. He himself proclaims himself naughty almost with satisfaction: +his doll is naughty, the dog is naughty, his nurse and mother are +naughty, and so forth. In reality the little child is peculiarly +sensitive to blame, if he is not reproof-hardened. It is hardly +necessary to use words of blame at all. If he is asked kindly and +quietly to desist, much as we would address a grown-up person, and +does not, he can be made to feel that his conduct is unpopular by +keeping aloof from him a little, by disregarding him for the time +being, and by indicating to him that he is a troublesome little person +with whom we cannot be bothered. + +Any one who has had much to do with children will realise that, if +wrongly handled, they are apt to take a positive delight in doing what +they conceive to be wrong. There is clearly a delightful element of +excitement in the process of being naughty, of daring and of braving +the wrath to come, with which they are so familiar and for which they +care nothing at all. But the perverseness of which we are now speaking +has a different origin. It arises only when children are reproved, +appealed to, and expostulated with too often and too constantly. +Negativism is a symptom which is common enough in certain mental +disorders. The unhappy patient always does the opposite of what is +desired or expected of him. If he be asked to stand up he will +endeavour to remain seated, or if asked to sit he will attempt to rise +to his feet. Like many other symptoms of nervous disturbance which we +shall study later, this negativistic spirit is often displayed to +perfection by little children when the environment is at fault and +when grown-up people have too freely exercised authority. A mother, +anxious to induce her little son to come to the doctor, and knowing +well that her call to him to enter the room, as he stands hesitating +at the door, will at once determine his retreat to the nursery, has +been heard to say, "Run away, darling, we don't want _you_ here," with +the expected result that the docile child immediately comes forward. +To the doctor, that such a device should be practised almost as a +matter of course and that its success should be so confidently +anticipated, should give food for thought. It may shed light on much +that is to follow later in the interview. + +The question of punishment, like that of reproof, is beset with +difficulty. There are fortunately nowadays few educated mothers who +are so foolish as to threaten punishment which they obviously do not +intend to administer and which the child knows they will not +administer. It is clear that punishment must be rare or else the child +will grow habituated to it, and with little children we cannot be +brutal or push punishment to the point of extreme physical pain. It is +more difficult to say, as one is tempted to say, that all punishment +is futile and should be discarded. Probably mothers are like +schoolmasters in that no two schoolmasters and no two mothers obtain +their effects in exactly the same way or by precisely the same means. +Nor do all children accept reproof or submit to punishment in the same +way. Some make light of it and take a pleasure in defying authority. +Others are unduly cast down by the slightest adverse criticism. It is +generally true that extreme sensitiveness to reproof is a sign of a +certain elevation of character. Always we must remember that for a +mother to inflict punishment, whether by causing physical pain or +mental suffering, is to take on her shoulders a certain +responsibility. It is a serious matter if she has misapprehended the +child's act--if the sin was not really a sin, but only some perverted +action, the intention of which was not sinful, but designed for good +in the faulty reasoning of the child. A little girl, in bed with a +feverish cold, was found shivering, with her night-dress wet and +muddy. It was an understanding mother who found that her little +brother, having heard somehow that ice was good for fevered heads, had +brought in several handfuls of snow from the garden, not of the +cleanest, and had offered them to aid his sister's recovery. It need +hardly be said that punishment should always be deliberate. The hasty +slap is nothing else than the motor discharge provoked by the +irritability of the educator, and the child, who is a good observer on +such points, discerns the truth and measures the frailty of his judge. + +The frequent repetition of words of reproof and acts of punishment has +a further disadvantage that the older children are quick to practise +both upon their younger brothers and sisters. There is something wrong +in the nursery where the lives of the little ones are made a burden to +them by the constant repression of the older children. But although +set and artificial punishments are as a general rule to be used but +sparingly, the mother can see to it that the child learns by +experience that a foolish or careless act brings its own punishment. +If, for example, a child breaks his toy, or destroys its mechanism, +she need not be so quick in mending it that he does not learn the +obvious lesson. If the baby throws his doll from the perambulator, in +sheer joy at the experience of imparting motion to it, she need not +prevent him from learning the lesson that this involves also some +temporary separation from it. Throughout all his life he is to learn +that he cannot eat his cake and have it too. The use of rewards is +also beset with difficulties. Their coming must be unexpected and +occasional. They must never degenerate into bribes, to be bargained +for upon condition of good behaviour. Rewards which take the form of +special privileges are best. + +The aesthetic sense of children develops very early. From the very +beginning of the second year they take delight in new clothes, and in +personal adornment of all sorts. They show evident pleasure if the +nursery acquires a new picture or a new wall-paper. They have +pronounced favourites in colours. Even tiny children show dislike of +dirt and all unpleasant things. Personal cleanliness should be clearly +desired by all children. A sense of what is pleasant and what is +unpleasant should be encouraged. Any delay in its appearance is apt to +imply a backwardness in development of mind or of body. Only children +who are tired out by physical illness or by nervous exhaustion will +lie without protest in a dirty condition. + +Affection and the attempt to express affection appear clearly marked +even in the first year. Too much kissing and too much being kissed is +apt to spoil the spontaneity of the child's caresses. We must not, +however, expect to find any trace in the young child of such a complex +quality as unselfishness or self-abnegation. The child's conception of +his own self has but just emerged. It is his single impulse to develop +his own experience and his own powers, and his attitude for many +years is summed up in the phrase: "Me do it." We must not expect him +to resign his toys to the little visitor, or the little visitor to +cease from his efforts to obtain them. In all our dealings with +children we must know what we may legitimately expect from them, and +judge them by their own standards, not by those of adult life. We +cannot expect self-sacrifice in a child, and, after all, when we come +to think of it, obedience is but another name for self-sacrifice. If +the tiny child could possibly obey all the behests that are heaped +upon him in the course of a day by many a nurse and mother, he would +truly be living a life of complete self-abnegation. Surely it is +because the virtue of obedience, the virtue that is proclaimed +proverbially the child's own, is so impossible of attainment that it +is become the subject of so much emphasis. As Madame Montessori has +put it: "We ask for obedience and the child in turn asks for the +moon." Only when we have developed the child's reasoning powers, by +treating him as a rational being, can we expect him deliberately to +defer his wishes to ours, because he has learned that our requests are +generally reasonable. + + + + +CHAPTER III + +WANT OF APPETITE AND INDIGESTION + + +The mind of the child is so unstable and yet so highly developed, that +symptoms of nervous disturbance are more frequent and of greater +intensity than in later life. Only rarely and in exceptional cases do +certain symptoms, common in childhood, persist into adult life or +appear there for the first time, and then usually in persons who, if +they are not actually insane, are at least suffering from intense +nervous strain. We have already mentioned the symptom of negativism +and noted its occasional occurrence as an accompaniment of mental +disorder in adult life, and its frequency among children who are +irritable or irritated. Similarly, we may cite the digestive neuroses +of adult life to explain the common refusal of food and the common +nervous vomiting of the second year of life. Thus, for example, there +exists in adult life a disturbance of the nervous system which is +called "anorexia nervosa." A boy of nineteen was brought to the +Out-patient Department of Guy's Hospital suffering from this +complaint. He was little more than a skeleton, unable to stand, hardly +able to sit, and weighing only four and a half stones. His mother, +who came with him, stated that he had always been nervous, and that +lately, after receiving a call to join the army as a recruit, his +appetite, which had for some time been capricious, had completely +disappeared. In spite of coaxing he resolutely refused all food, or +took it only in the tiniest morsels, although at the same time it was +thought that he sometimes took food "on the sly." A careful +examination showed absolutely no sign of bodily disease. He was +admitted to a ward for treatment by hypnotic suggestion, but before +this could be begun he endeavoured to commit suicide by setting fire +to his bed. + +A girl of twenty-four years of age had become almost equally +emaciated. Constant vomiting had persisted for many years and had +defied many attempts at cure. It had even been proposed to perform the +operation of gastro-enterostomy in the belief that some organic +disease existed. In suitable surroundings and with the energetic +support of a good nurse, who spent much time and care in restoring her +balance of mind, the vomiting ceased, and she gained over two stones +in weight. Work was found for her in some occupation connected with +the War, and she left the Nursing Home to undertake this, bearing with +her four pounds which she had abstracted from the purse of another +patient. + +Those who have not opportunities of observing how all-powerful is the +effect of the mind upon the body, and especially perhaps upon the +process of digestion, may find it hard to believe that these +distressing symptoms and profound changes in the aspect and nutrition +of the patients were due entirely to mental causes and were symptoms +in accord with the attempted suicide or the theft of the money. In +nervous little children we shall not often find such complex actions +as suicide or theft, although they do occur, but combined with other +evidence of nervousness we shall meet commonly enough with a +persistent setting aside of appetite and refusal of food and with +continuous and habitual vomiting, from nervous causes. + +The experiments of Pawlow and others have explained the dependence of +digestion upon mental states. They show that even before the food is +taken into the mouth, while the meal is still in prospect, there has +been instituted a series of changes in the wall of the stomach, which +gives rise to the so-called psychic secretion of gastric juice. These +changes are preceded by the sensation of appetite, which is evoked not +by the presence of food in the stomach--for the food has not yet been +swallowed--but by the anticipation of it, by the sight and smell of +food, as well as by more complex suggestions, such as the time of day, +the habitual hour, the approach of home, and so forth. + +Emotional states of all sorts--grief, anger, anxiety, or +excitement--put a stop to the process or interfere with its action, so +that the sense of appetite is absent, and the taking of food is apt to +be followed by discomfort or pain or vomiting. No doubt good digestion +leads to a placid mind, but it is equally true that a placid mind is +necessary for good digestion. Therefore we civilised people, living +lives of mental stress and strain, try to increase the suggestive +force of our surroundings and to provoke appetite by all devices +calculated to stimulate the aesthetic sense. The dinner hour is fixed +at a time when all work and, let us hope, all worry is at an end for +the day. The dinner-table is made as pretty as possible, with flowers +and sparkling glass. We are wise to dress for dinner, that with our +working clothes we may put off our working thoughts. + +In the treatment of adult dyspepsia we seldom succeed unless we can +place the mind at rest. We may advise a visit to the dentist and a set +of false teeth, or we may administer a variety of stomach tonics and +sedatives, but if the mind remains filled with nameless fears and +anxieties we shall not succeed. + +In adult life the nervous person when subjected to excessive stress +and strain is seldom free from dyspeptic symptoms of one sort or +another, and what is true of adult life is even more true of +childhood, when the emotions are more poignant and less controlled. +Then tears flow more readily than in later life, and tears are not the +only secretions which lie under the influence of strong emotion. +Emotional states, which would stamp a grown man as a profound +neurotic, are almost the rule in infancy and childhood, and may be +marked by the same physical disturbances--flushing, sweating, or +pallor, by the discharge of internal glandular secretions as well as +by inhibition of appetite, by vomiting, gastric discomfort, or +diarrhoea. Naturally enough, mothers and nurses are wont to demand a +concrete cause for the constant crying of a little child, and +teething, constipation, the painful passage of water, pain in the +head, or colic and indigestion are suggested in turn, and powders, +purges, or circumcision demanded. There can be no doubt that nervous +unrest is capable of producing prolonged dyspepsia in infancy and +childhood--a dyspepsia which, while it obstinately resists all +attempts to overcome it by manipulation of the diet, is very readily +amenable to treatment directed to quiet the nervous system. + +Where a primary dyspepsia exists for any length of time, the growth +and the nutrition of the child is clearly altered for the worse. The +character of the stools, their consistency, smell, and colour, is apt +to be changed because the bacterial context of the bowel has become +abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, +prolapse of the rectum, and infection with thread-worms are common +complications. No doubt children with primary dyspepsia are often +nervous and restless, and the elements of infection and of neurosis +are frequently combined. Yet often we meet with cases in which the +gastric or intestinal disturbance comes near to being a pure neurosis. +The nutrition, then, seldom suffers to any very great extent, or to a +degree in any way comparable to that which is characteristic of +dyspepsia from other causes. Emaciation, wrinkling of the skin, +dryness and falling out of the hair, decay of the teeth, are not as a +rule part of the picture of nervous dyspepsia. The child may be slim +and thin and nervous looking, but as a rule he is active enough, with +a good colour and fair muscular tone, so that one has difficulty in +believing the mother's statements, which are yet true enough, as to +the trouble which is experienced in forcing him to eat, or as to the +frequency of vomiting. + +In early childhood the difficulty of the refusal of food often passes +or diminishes when the child learns to feed himself with precision and +certainty. To teach him to do so, it is not wise to devote all our +attention to making him adept at this particular task. The fault is +that the brain centres which control the movements of hands, mouth, +and tongue have not been developed, because his activities in all +directions have not been encouraged. It is much less trouble for a +nurse to feed a little child than to teach him to feed himself, and if +he is not given daily opportunities of practice he will certainly not +learn this particular action. But the fault as a rule lies deeper. The +child who cannot feed himself cannot be taught until fingers and brain +have been developed in the thousand activities of his daily routine, +by which he acquires general dexterity. A child who is still too young +to feed himself is learning the dexterity which is necessary as a +preliminary in every action of the day. If he can carry the tablecloth +and the cups and saucers to the tea-table, imitating in everything the +action of his nurse, it will be strange if he does not also imitate +her in the central scene, the actual eating of the food. If, on the +other hand, he is waited upon hand and foot, if he is restrained and +confined, sitting too much passively, now in his perambulator, now in +his high chair, now on his nurse's lap, his imitative faculties and +his tactile dexterity alike remain undeveloped. The child who is slow +in learning to feed himself shows his backward development in every +movement of his body. One may note especially the stiff, +"expressionless" hands, indicating a general neuro-muscular defect. I +have seen many children of eighteen months or two years of age in whom +the movements necessary for efficient mastication and swallowing had +failed to develop satisfactorily. In some a pure sucking movement +persisted, so that when, for example, a morsel of bread or rusk was +put in the child's mouth, it would be held there for many minutes and +submitted only to suction with cheeks and tongue. Attempts to swallow +in such a case are so incoordinate that they give rise frequently to +violent fits of choking, which distress the child and produce +resistance and struggling, while at the same time they alarm the +mother or nurse so much that further attempts to encourage the taking +of solid food are hastily and for a long time abandoned. In this +helpless condition the other factors which tend to develop what we +have called negativism have full play. The want of imitation and the +lack of dexterity is not the sole or perhaps the main cause of the +child's refusal of food and of the apparent want of appetite, but it +is the cause of the failure to learn to feed himself, which places +him in a condition which is peculiarly favourable to the operation of +other factors. If only we can teach the child to feed himself, the +difficulties of the situation become much less formidable. + +The first of the factors which encourage the persistent refusal of +food is the extreme susceptibility of the child to suggestion. A +particular article of diet may be refused on one occasion, perhaps in +pique, because another more favoured dish was hoped for or expected, +or perhaps because the taste is not yet familiar. Then if on this +occasion a struggle for the mastery is waged, and a painful impression +is made on the child's mind connecting this particular dish with +struggling and tears, from that day forward the child may persistently +refuse it on every occasion it is offered. Matters are made worse if +the nurse, anticipating refusal, attempts to overcome the resistance +by peremptory orders, or by excessive praise extolling the delicious +flavour with such fervour that the child's suspicions are at once +aroused. Previous experience has made him connect these excessive +praises with articles which have aroused his distaste. If these fads +and fancies on the part of the child are to be avoided, it is +essential that we should do nothing to focus his attention on his +refusal. It is better that his dinner should be curtailed on one +occasion than that taste and appetite should be perverted perhaps for +years. Every nurse or mother should cultivate an off-hand, detached +manner of feeding the child, and should patiently continue to offer +the food without uncalled-for comments or exhortations. Let her always +remember the force of suggestion on the child's mind, and that a +confident manner which never questions the child's acceptance will +meet with acceptance, while a hesitating address, from fear of the +impending refusal, will be apt to meet with refusal. Sometimes a still +worse fault manifests itself, when nurse and mother speak before the +child of the smallness of his appetite, and of his persistent refusal +of this or that article of diet. The suggestion then acts still more +powerfully on his mind. He is aware that the whole household is +distressed by his peculiarity, and he grows to identify it with his +own individuality, and to regard himself with some satisfaction as +possessing this mark of distinction. If there is any difficulty of +this sort it is often directly curative to reverse the suggestion and +to speak before him of his improving appetite, and to say that he +begins every day to eat better and better, even if to do so we have to +break a good rule never to say to the child what is not strictly true. +Or once or twice we may take his plate away before he has finished, +saying positively that he has eaten so much that he must eat no more. +If in spite of every care antipathies to certain articles of food +appear and persist, we must be content to bide our time. When the +child grows of an age to reason, we should seize every opportunity to +make him feel that his persistent refusal is a little ridiculous and +childish. Little by little the seed is sown, and will germinate till +one day we shall note with surprise that he has taken of his own +accord that which he has neglected for so long and with such +obstinacy. + +But the force which is acting most strongly in producing this refusal +of food is the force of which we have spoken in a previous +chapter--the force which results in negativism, the force which is in +reality the habit of opposition, the love of power, and the desire to +attract attention. Here again the refusal of food, if due to this +cause, is never the sole manifestation of the fault. Just as the delay +in learning to swallow and to chew properly and to feed himself is +part of a general want of dexterity and capacity manifested in all his +actions, so it will seldom happen that the child's anxiety to oppose +is only seen at meal-times. Watch a nervous child in the nursery +before the dinner hour. He is cross and restless and inclined to cry. +The nurse hands him a doll, and he throws it away saying, "No, no +doll." At the same moment he may catch sight of his ball, and it too +is violently rejected, "No, no ball." Everything in turn is treated in +the same way. Finally he falls upon his nurse, crying and beating her +with his hands, saying, "No, no Nurse." If that long-suffering woman +at that moment summons him to dinner, it will be strange indeed if his +attitude is not "No, no dinner," and "No, no" to every mouthful +offered him. How strong this love of opposition may be is illustrated +by the case of a little boy who was brought to me for refusal of food. +Three weeks before, he had been taken in a motor-car to his +grandfather's to midday dinner on Sunday, when his absolute refusal of +food had spoiled the day and had occupied the attention and the +efforts of the whole party. Doubtless he had enjoyed himself, for +three weeks later, when he caught sight of the car which was to bring +him to me, and which he had not seen in the interval, he at once said, +"Not eat my dinner." This child's father told me that the sight or +sound of the preparation of a meal was enough to bring on a paroxysm +of opposition. Now this force of opposition, as we have seen, only +develops into a serious difficulty when the child's own will has been +opposed too much, when authority has been too freely exercised, and +when the child has been urged and entreated and reproved with too +great frequency. His opposition grows with all counter-opposition. And +he is not really naughty, only irritable and restless from the +thwarting of his natural impulses, and unable to express his thoughts +and desires. Negativism will not often confine itself to meal-times. +It will show clearly in all the actions of the child, and to get him +to eat well and freely we must so change our management of him that +negativism disappears or at least diminishes. There is no other way. +No entreaty, no force, no threats of force will ever succeed, but will +only make him worse, and, since negativism is due to mental unrest, +the struggles and crying will only perpetuate the cause. The one way +to banish negativism and overcome the opposition is to cease to +oppose, and to practise this aloofness not so much at meal-times, for +somehow by patience the child must be got to take his food, but in all +our conduct to him. Repression and reproof, and thwarting of the +child's will, and coaxing and entreaty must cease. There is no fear +that we shall thereby make the child unduly disobedient. We have +already, in another chapter, decided that negativism is not strength +of will on the part of the child which must be broken, but is the +result of constant attempts to oppose his nature, and the consequent +nervous unrest. If we cease to oppose, the symptoms will tend rapidly +to disappear, the child will become busy and contented and happy in +his play, and we shall hear no more of his refusal of food. If +sometimes it recurs for a week or two, we shall know how to deal with +it. + +In children, as with us, periods of nervous unrest and unhappiness are +apt to recur in a sort of cycle. This cyclical character of mental +disturbance is often a marked feature. We see it in epilepsy and +in what the French have called Folie Circulaire. We see it in the +dipsomaniac, in the intermittency of his craving for drink and of his +periodical outbursts, and we see it in ourselves in those periods of +depression which recur so often, we know not why. Little children too +sometimes get out on the wrong side of their beds, and never get right +the whole long day. Their own experience of the vagaries of mental +states should lead mothers to be indulgent to the children in their +days of cloud and to be particularly careful not to goad them by +well-intentioned efforts into bursts of naughtiness and passion, each +one of which tends to perpetuate the condition and increase the +nervous unrest. We know how closely dependent is the sensation of +appetite upon emotional states, and we must do all in our power--and +the task is sometimes one of real difficulty--to keep the child's mind +sufficiently at rest to preserve the healthy desire for food +unimpaired. If there is no sign of appetite, but every sign of +restlessness and irritability, we must seek in the management of the +child until we find the fault. + +If food is taken mechanically and without appetite, if the preliminary +changes in the stomach wall which are necessary for adequate digestion +do not take place, but are inhibited by the mental unrest, the meal is +apt to be followed by gastric pain and discomfort, or, more commonly +with children, the stomach may promptly reject its contents. At the +worst, nervous vomiting of this sort may follow almost every meal, +although, again, it is curious to note how little, comparatively +speaking, the nutrition of the child suffers. The vomiting too, as in +adults, comes very near being a voluntary act, and mothers and nurses +will often remark that they get the impression that it can be +controlled at will. If once the diagnosis is made that the want of +appetite or the vomiting is of nervous origin, the treatment of the +condition is clear. Sedative drugs directed towards quieting the +nervous excitability may be of service, but tonics, appetisers, +laxatives, and drugs with a direct action on the stomach will have but +little effect. Nor is there as a rule anything to be gained by +modifying the diet or by excluding this or that article of food. The +frequency of the vomiting is such that it is apt to have brought +discredit one after the other upon almost every article of food which +the child can take, with the result that many useful and necessary +foods have been abandoned for long on the ground that they are the +cause of the dyspepsia. A permanent cure will only be effected when +the faults of environment have been overcome, when the cause of the +nervous unrest has been removed, and when the child's mind is at +peace. + +Nervous vomiting of this kind is not difficult to control, if those in +charge of the children can be made to understand that the cause lies +in the anxiety which they themselves show before the child, increasing +his own apprehension or adding to his sense of power or importance. +Once the child is convinced that his conduct excites no particular +interest, the vomiting soon ceases. In more than one instance, +vomiting which has persisted for many months has stopped at once after +the matter has been fully explained to the parents. In the most +inveterate case of this sort which has come under my notice, the child +was regularly sick as soon as he caught sight of a white cloth being +laid on the table for meals. Yet even this child never vomited when he +was under the charge of a particular nurse who had to return more than +once to the family, and on each occasion was successful in breaking +the habit. + + + + +CHAPTER IV + +WANT OF SLEEP + + +So far, almost all that has been written--and there has been a great +deal of unavoidable repetition--has been devoted to an attempt to +determine the causes which lead the child to refuse food and the +methods which we adopt to prevent or overcome the difficulty. Other +neuroses may be studied in less detail, because they depend for their +existence upon the same causes. For example, the habit of refusing +sleep, which is as common and almost as distressing as the habit of +refusing food, depends both upon a perversion of suggestion and upon +the phenomenon that we have called negativism. + +If struggling and crying has occurred upon a series of nights, the +child comes to associate his bed not with sleep but with tears. If a +mother values her peace of mind, if she would spare herself the +discomfort of hearing her child sob himself nightly into uneasy sleep, +she must be wary how this all-important event of going to bed is +approached. With a nervous and restless child the preliminaries of +preparing for bed must be managed carefully and tactfully. The hour +before bedtime is almost universally the most interesting of the +whole day for the child. Then the baby, with his best frock on, and +books and toys, is the centre of interest in the drawing-room, till +the clock strikes and the nurse appears at the door. Suddenly it is +all over, and inexorable routine sends him off to bed. The good nurse +will give the child a little time to recover from the shock of her +arrival, and will not hurry him. She knows that his little mind is +slow to act, and that he must be led gradually to face a new prospect. +If she hurries him, catching him up in her arms from the midst of his +unfinished pursuits, resistance and tears are almost sure to follow, +and the difficult task of the day--the putting to bed--has made the +worst possible start. When this has happened on one or two successive +evenings, the habit of resistance to going to bed becomes fixed, and, +like all bad habits, is difficult to break. A nurse who has a way with +children will arouse his interest in a new pursuit, in which he can +play the chief part, the putting away of his picture books and toys. +If he is too small to carry his own chair or table to its allotted +place in the room, at least he can show his learning by pointing out +the spot. In the waving of good-byes he is expert and takes a +legitimate pride, and upstairs he has learnt that there are new +delights. He himself can turn on the taps in the bathroom, and he can +set every article in the proper place ready for use. All children love +their bath, and if interest and good temper has been so far preserved, +without a break, it will be ill-fortune if even the drying process is +not carried off without a hitch. Afterwards, for a little, nervous +babies, whose brains still teem with all the excitements of the day, +are best left to sit for a few moments by the nursery fire, while the +nurse puts all the garments one by one to bed. Each as it goes to rest +will be greeted by him with cheerful farewells; and so does the force +of suggestion act, till the central figure himself plays his part in +the scene, of which he feels himself the controller and director, and +climbs to bed. But if there has been a hitch anywhere, if the bugbear +of negativism has appeared, if he has been scolded or coaxed or +repressed too much and there have been tears and struggles, then going +to bed is a poor preparation for instant and quiet sleep. + +With excitable, highly-strung children, the best laid plans and the +most tactful nurse will not always succeed, and to place him in his +cot is to provoke a storm of angry refusal and resistance. There are +mothers who believe that the best way is then to turn out the light +and leave the child to cry himself to sleep. This is a point on which +no one can lay down rules which are applicable for all children. It +may sometimes succeed, and the child may reason correctly and in the +way we wish him to reason, deciding that the game is not worth the +candle and so give it up. But with nervous, highly-strung children I +doubt if this Spartan conduct is commonly successful. Often if the +attempt is made, the troubled mother, listening to all these +heart-breaking sobs, can bear it no longer, and goes back to the side +of the cot to soothe and persuade him. Then certainly the longer she +has restrained her natural inclination, the longer the child has +sobbed himself into a pitiful little ball of perspiration and tears, +the more difficult will be her task in quieting him, the stronger will +be the impression formed on the child's mind, and the greater will be +the suggestion which will act under the same circumstances to-morrow. +Children who fall a prey to this uncontrolled crying, cry on because +they cannot stop when they have begun. They do not then cry purposely +or with a fixed intention, desiring to attain some object. They cry +because their minds are not at rest, but are irritated and overwrought +by the happenings of the day. We decided that it was useless to +attempt by exhortations at meal-times to induce a nervous child to eat +who habitually refuses food, and that we can only cure the condition +by eliminating from his daily life the elements of repression and +opposition which provoke the counter-opposition. And we must seek the +same solution in this other difficulty of the refusal of sleep. It is +useless to attempt to treat the symptom of refusal of sleep and to +leave the cause of that symptom still constantly in action. + +If, in spite of our care to avoid unrest and irritation of the child's +brain, sleep is refused, as may often happen, it is, as a rule, wise +to cut short the crying if we can, before a vicious circle has been +formed and the unrest has been intensified by the emotional storm. It +is useless with little children to urge them to go to sleep or to +coax. It is not usually wise to leave the child for a little and then +to return. Each time the child is left, each time the mother or nurse +returns, the crying bursts forth again with renewed force and vigour. +It is at least one good plan with a little child to turn the light +out, and, treating the whole incident in the most matter-of-fact way +possible, lightly to stroke his head or pat his back rhythmically +without speaking. With older children, if the crying is more +purposeful and less emotional, the mother may busy herself for a +little with some task in the room, ostentatiously neglecting the storm +and making no reference to it. If she speaks to the child at all she +should do so in a matter-of-fact way, referring lightly to other +matters. If only she can convince him that his conduct is a matter of +indifference to her, the victory is won. It is because the child knows +so well that his mother does care that he so often has the upper hand. +It is not difficult to distinguish between a true emotional storm and +the tyrannous cry of a wilful child who demands his own way. + +Light and broken sleep is a common accompaniment of a too excitable +and overstimulated brain. The placid child, who eats well, plays +quietly, and does not cry more than is usual, as a rule sleeps so +soundly that no ordinary sounds, such as conversation carried on in +quiet tones in his neighbourhood, have the power to waken him. When he +wakes, he does so gradually, perhaps yawning and stretching himself. +The nervous child may move at the slightest sound, or with a sudden +start or cry is wide awake at once. A hard mattress should be chosen +without a bolster, and with only a low pillow. Flannel pyjamas, which +cannot be thrown off in the restless movements of the child, should be +worn. The temperature of the room should be cool, and the air from the +open window should circulate freely, while draughts may be kept from +striking on the child by a screen. All the sensations of the nervous +child are abnormally acute. Thus, for example, an itching eruption, or +tight clothing, will produce an altogether disproportionate reaction, +and may result in a frenzy of opposition. Especially such a child is +sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool +rooms and warm but light and porous clothing are essential. An +electric torch, which can be flashed on the child for an instant, will +assist the mother or nurse to make sure that the child has not thrown +off all the bedclothing. + +Sometimes want of sleep is accounted for by a real want of physical +exercise. Town children especially are apt to suffer from their +limited opportunities of running freely in the open. It is often +considered enough that the child seated in his perambulator should +take the air for three or four hours daily, while much of his time +indoors as well is devoted to sitting. It is necessary for his proper +development that he should have opportunities of daily exercise in the +open. If for any reason this is not always practicable, a large room, +as free as possible from furniture, should be chosen, with windows +thrown wide open, in which the child may romp until he is tired. + +It is rare for children of two or of three years of age, whose case +we are now considering, to be troubled by bad dreams, nightmares, or +night-terrors. If these should occur, obstructed breathing due to +adenoid vegetations is sometimes at work as a contributory cause. + +Finally, we should always remember that refusal of sleep is, for the +most part, caused and kept up by harmful suggestions derived from +mother and nurse, who allow the child to perceive their distress and +agitation, who speak before the child of his habitual wakefulness, who +unwittingly focus his attention on the difficulty. It is cured in the +moment that the suggestion in the child's mind is reversed, in the +moment when he comes to regard it as characteristic of himself not to +make a fuss about going to bed, but to sleep with extraordinary +readiness and soundness. Let every one join together to produce this +effect. Let the suggestion act strongly on his mind that all these +troubles of sleeplessness are diminishing, that night after night sees +an improvement, and soon his reputation as a good sleeper will be +established, and, as always with children, it will be rigidly adhered +to. + +In assisting to break the habit of sleeplessness, and in the process +of altering the character of the suggestions which act on the child's +mind, we can be of the greatest assistance to the mother by +prescribing a suitable hypnotic. As to whether it is right in insomnia +in childhood to prescribe depressant drugs is a question on which very +various opinions are held. That it is wrong and probably ineffective +to trust entirely to the drugs is certainly true, but as a temporary +measure, to break the faulty suggestion and the bad habit, their use +is both legitimate and successful. The dose required in children +relatively to the adult is much smaller. In grown people, some +specific distress of mind, whether real or imaginary, may suffice to +resist very large doses of hypnotic. In children it is rare to find +the same resistance, and comparatively small doses have a very +constant effect. With deeper and more refreshing sleep, the conduct of +the child during the day almost always changes for the better. A sound +sleep, for a few nights in succession, will produce apparently quite a +remarkable change in the whole disposition of the child. When good +temper and interest take the place of fretfulness and restlessness, we +may confidently expect that the symptom of sleeplessness will begin to +abate. Sleeplessness by night and fretfulness by day form a vicious +circle, and attempts must be made to break it at all points. + +Chloral occupies the first place as a hypnotic for young children. In +combination with bromide its effects are wonderfully constant and +certain. Two grains of chloral hydrate and two grains of potassium +bromide with ten minims of syrup of orange, given just before bedtime, +will bring sound sleep to a child of a year old. At three years the +dose may be twice as great, and three times at six years. It is seldom +that other means are required. Aspirin for children seems relatively +without effect. For children who are both sleepless and feverish, a +grain of Dover's powder, and a grain of antipyrin, for each year of +the child's age up to three, is very helpful. Lastly, if chloral and +bromide cannot break the insomnia, and the condition of the child is +becoming distressing, we can almost always succeed if we combine the +prescription with an ordinary hot pack for twenty minutes. + + + + +CHAPTER V + +SOME OTHER SIGNS OF NERVOUSNESS + + +HABIT SPASM + +Next to refusal of food and refusal of sleep perhaps the most frequent +manifestation of nervous unrest is provided by the group of symptoms +which we may call, with a certain latitude of expression, Habit +Spasms. By a habit spasm is meant the constant repetition of an action +which was originally designed to produce some one definite result, but +which has become involuntary, habitual, and separated from its +original meaning. The nervous cough forms a good example of a habit +spasm. A cough may lose its purpose and persist only as a bad habit, +especially in moments of nervousness, as in talking to strangers, in +entering a room, or at the moment of saying "How do you do" or +"Good-bye." Twitching the mouth, swallowing, elongating the upper lip, +biting the lips, wrinkling the forehead so strongly that the whole +scalp may be put into movement, and blepharospasm are all common +tricks of little children which may become habitual and uncontrolled. +In worse cases there may be constant jerking movements of the head, +nodding movements, or even bowing salaam-like movements. In mild +cases we may note hardly more than a restless movement of mouth or +forehead, or constant plucking or writhing of the fingers whenever the +child's attention is aroused, when he is spoken to, or when he himself +speaks. In nervous children these movements, which should properly be +confined to moments of real emotional stress, become habitual, and are +displayed apart from the excitement of particular emotions. Whatever +their intensity, habitual and involuntary movements of this nature +should not be overlooked, and should be regarded as evidence of mental +unrest. They do not commonly appear during the first or second years +of the child's life. They are more frequent after the age of five, but +they may begin to be marked as early as the third year. With refusal +of food and refusal of sleep they form the three common neuroses of +early childhood. + +Two of the three qualities which we have mentioned as characteristic +of the child's mind are concerned in the causation of habit spasm. In +the early stages the movement is sometimes due to imitation, but the +susceptibility of the child to suggestion plays the chief part in +determining its persistence. It is an interesting speculation how far +tricks of gesture, attitude, or gait are inherited and how far they +are acquired by imitation. A child by some characteristic gesture may +strikingly call to mind a parent who died in his infancy. A whole +family may show a peculiarity of gait which is at once recognisable. +It is told of the son of a famous man, who shared with his father the +distinctive family gait, that when a boy his ears were once boxed by +an old gentleman who chanced to observe him hurrying to overtake his +parent, and who resented what he took to be an act of impertinent +caricature. In the reproduction by the child of the habitual actions +of his parents, heredity is largely concerned, but imitation too plays +its part. In habit spasm the force of imitation is clearly seen. A +child who has developed a habit spasm of one sort or another will +readily serve as a model to other children. The malady will sometimes +spread through a school almost with the force of a contagious +disorder. A child affected in this way may prove an unwelcome guest. +The little visitor with a trick of contorting his mouth and grimacing +is apt to leave his small host an expert in faithfully reproducing the +action. A cough that is genuine enough in one member of the family may +produce a crop of counterfeits in brothers and sisters. + +The force of suggestion acting upon the child's mind can clearly be +traced. Once his attention is focused upon the particular movement by +unwise emphasis on the part of the parents, he loses the power to +control its occurrence. This trio of common neuroses--refusal of food, +refusal of sleep, and habitual involuntary movement--grows only in an +atmosphere of unrest and apprehension. Parents and nurses anxiously +watch their development. They are distressed beyond measure to note +their steady growth in spite of every attempt which they make to +control or forbid them. And of all this unrest and unhappiness the +child is acutely conscious. The whole household may become obsessed +with the misfortune which has befallen it, and the mother, losing all +sense of proportion, feels that she cannot regain her peace of mind +until it has been overcome. The child is in need of mental and moral +support from those around him, and all that he finds is an openly +expressed apprehension and sense of impotence. Even grown-up people, +when their nerves are on edge, are apt to be obsessed by +uncontrollable impulses or by vague and nameless apprehensions, and +surely all have learnt the support they gain from contact and +conversation with some one strong and sane, who treats their worries +in such a matter-of-fact way that immediately they lose their power +and become of no account. The child with habit spasm cannot control +these movements. The more he is reproved or entreated, the less able +does he find himself to hold them in check. He does not wish them to +continue. He has lost control of what he once controlled, and the +realisation of this is not pleasant, and may be alarming to him. Yet +when unconsciously he looks to his mother for support, he finds in her +open dismay that which serves only to increase his uneasiness. She +must subdue her own feelings and give the child strength. If she +treats the whole thing in a matter-of-fact way, as a temporary +disturbance which is of no importance in itself, and only has meaning +because it implies that the brain has been over-stimulated, she will +no longer exercise a prejudicial effect on the child. If the bad habit +is taken as a matter of course, if too much is not made of it, if the +child is encouraged to think that nobody cares much about it at all, +then recovery will soon take place. It goes without saying that habit +spasms and tics of all sorts are made worse by excessive emotional +display and by nervous fatigue. On the other hand, if the child +becomes absorbed in some interesting occupation, the movements will +disappear for the time being. + + +AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING + +At a somewhat earlier age than that in which habit spasms become +common, and before bed wetting appears as a formidable difficulty, we +meet with another group of habitual actions which yet retain their +voluntary character. Among such habitual actions are thumb sucking, +thigh rubbing, and air swallowing. If the child is old enough to +express himself on the subject, he will explain that these actions are +performed because of the satisfaction derived from them, because it is +"comfy" and "nice." Even if the child is too small to speak, the +expression is that of beatitude and content. These actions are not +confined to nervous children, and their occasional practice need not +be taken to imply that there is any strong element of nervous +overstrain. It is only when the action is repeated with great +frequency and persistence, and when signs of irritation ensue if +gratification is not obtained, that we are justified in classing it +among the symptoms of mental unrest. + +The second of these actions, thigh rubbing, is found for the most +part in little girls, and inasmuch as it consists of a stimulation of +the sexual organs sometimes causes much distress to the parents. It is +in reality a habit of small importance unless exercised with very +great frequency. It is, of course, not associated in the child's mind +with any sexual ideas, and is of precisely the same significance as +the other two actions of the same class. Children who can speak will +refer to it openly without any sense of shame. As a rule the action is +performed in a half-dream state, that condition between sleeping and +waking which is found when the child is lying in the morning in her +cot or in her perambulator after the midday nap. The child's attention +should not be focused on the symptom. She should lie on a hard +mattress, and when she wakes in the morning she should either leave +her cot at once or she should be roused into complete wakefulness by +encouraging her to play with her toys. Little children should be +taught to sleep with their hands folded and placed beside the cheek. +If the movement occurs on going to sleep, it is best left alone and +completely neglected. As a rule each child has his or her own +favourite action of this class, and they are seldom combined in the +same child. If thigh rubbing is very constant and obstinate and does +not yield to the measures suggested, it may even sometimes be a +successful manoeuvre to substitute the thumb-sucking habit in the +expectation that this less distressing habit may eject the other more +objectionable action. As a rule, however, a wise neglect and careful +watching during the drowsy condition that follows sleep in a warm bed +will succeed in stopping the practice of thigh rubbing before the end +of the second or third year. Apparatus designed to restrain movement +of the child's legs or blistering the opposed surfaces of the thighs +are both of no effect. They have indeed the positive disadvantage that +they focus the child's attention on the practice. The habit ceases +only when the child has forgotten all about it, and these devices +serve only to keep it in remembrance. The same may be said of any +system of punishments. Further, we cannot always have the child under +observation, and at some time or other opportunity will be found for +gratification. Of older children, in whom self-control and a sense of +honour can be cultivated, I am not here speaking. + +Air swallowing is less common than thigh rubbing, but belongs to the +same group of actions and takes place in the same drowsy condition. +The child will rapidly gulp down air which distends the stomach, and +is then regurgitated with a loud sound. Thumb sucking seldom +distresses the mother to the same extent, and the proper attitude of +tolerance is adopted towards it. If much is made of it, it is +astonishing how persistent the habit may become, surviving all +attempts to forbid it, to break it by rewards or punishments, or to +render it distasteful by the application of a variety of ill-tasting +substances smeared on the offending digit. + +PICA AND DIRT EATING + +Certain other bad habits will become ingrained if attention is called +to them, because of that curious spirit of opposition which +characterises little children, and because of their susceptibility to +suggestion. Some children will constantly pluck out hairs and eat +them, or will devour particles of fluff drawn from the blankets. +Others will seize every opportunity to eat unpleasant things, such as +earth, sand, mud, or dirt of any sort. All tricks of this sort are +best neglected and treated by attracting the child's attention to +other things. In adult life they are associated with serious mental +disturbance, in early childhood they are of little account, or at most +suggest a certain nervousness which may be due to nervous irritation +from faults of management which we must strive to correct. + + +CONSTIPATION + +As has been already mentioned, much of the common constipation of the +nursery is due to neurosis. The excessive concentration of the nurse's +thoughts on this daily question communicates itself to the child. The +difficulty is emphasised, and an attempt is made to substitute will +power for forces of suggestion which are at once inhibited by +concentration of the mind upon the process. Here also, just as in the +refusal of food, a further stage of "negativism," that is, of active +resistance with crying and struggling, is reached, so that complaint +may be made by the mother that defaecation is painful. The same +negativism may be shown in micturition, and mothers will give +distressing accounts of the suffering of the child during the passing +of water. + + +BREATH-HOLDING AND LARYNGISMUS STRIDULUS + +In some children, in the first two years of life, we find a definite +and measurable increase in the irritability and conductivity of the +peripheral nerves. The strength of current necessary to produce by +direct stimulation of the nerve a minimal twitch of the corresponding +muscle may be many times less than the normal. Of this heightened +irritability of the nervous system, to which the name "spasmophilia" +has been given in America and on the Continent, the most striking +symptom is a liability alike to tetany or carpo-pedal spasm, to +generalised convulsions, and to laryngismus stridulus. In addition, in +most cases it is generally possible to demonstrate the presence of +Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a +visible twitch of the facial musculature, especially of the +orbicularis palpebrarum or of the orbicularis oris, in response to a +gentle tap administered over the facial nerve in front of the ear. +Trousseau's sign is the production of tetany by applying firm and +prolonged pressure to the brachial nerve in the upper arm. The +aetiology of spasmophilia is still a matter for dispute, but the +evidence which we possess is in favour of the view that we have here +to deal with a disturbance of calcium metabolism. The calcium content +both of the blood and of the central nervous system has been shown to +be much lowered. It is in keeping with this that clinically we note +how frequently spasmophilia and rickets occur in the same child. In +some families the condition recurs through many generations. + +For our present purpose--the examination of some common neuroses of +nursery life--it would be out of place to enter into a detailed +consideration of this disorder of spasmophilia as a whole. The symptom +of laryngismus stridulus--the so-called breath-holding--alone need +concern us, and that for a special reason. The spasm of the glottis is +produced under the influence of any strong emotion--in anger, for +example, or in fear, in excitement or in crying for any reason. To +control or prevent it we must direct attention not only to the +condition of spasmophilia, but also to the management of the children +who are always excitable and emotional. In these children every burst +of crying, however produced, whether by a fall, by a fright, by the +entrance of a stranger, or by a visit to a doctor, is apt to be +ushered in by a long period of apnoea, due to spasm of the glottis +and of the diaphragm. The first few expirations are not followed by +any inspiration. For several seconds the silence may be complete, +while the child steadily becomes more and more cyanosed, or the body +may be shaken by incomplete expiratory movements and strangled cries +which are suppressed because the chest is already in a position of +almost complete expiration. In the worst cases, when the apnoea +lasts a very long time, there may be convulsive twitching of the +muscles of the face, or the attack may even terminate in general +convulsions. Very occasionally the spasm is actually fatal. In all +fatal cases which have come to my notice the child at the moment of +death had been alone in the room. I have met with no fatal case where +the baby could be picked up and assisted. As a rule, therefore, the +cause and mode of death must be conjectural, but when an infant is +found dead in its cot unexpectedly, it would seem likely that it has +waked from sleep with a sudden start, become excited, and, about to +cry, has been seized by the fatal spasm. In two instances reported to +me a cat had been found in the room with the dead child, and it was +suggested that the animal had lain upon the child's face. Both these +children, however, were vigorous and capable of powerful movements of +resistance. I think it more likely that the cat may have awakened them +in fright, and that the emotional excitement, giving rise to the +spasm, was the cause of the suffocation. That the apnoea in these +extremely rare instances should end fatally produces a difficult +position for the doctor. It need hardly be said that the seizures are +alarming to the parents. For the sake of great accuracy in the +statement of our prognosis are we to add a hundred times to the +mother's alarm by stating the possibility of death? In each case we +must use our own judgment. I believe that in a child over a year old +the risk is almost negligible. + +Fortunately in all save the rarest possible instances the apnoea +yields and a deep inspiratory movement follows. As the air rushes past +the glottis, which is still partially closed, a sound recalling the +whoop of pertussis is heard. Often this recurs throughout all the +burst of crying which follows, and each inspiration is accompanied by +a shrill stridulous sound. With the re-establishment of respiration +the cyanosis rapidly fades, to be succeeded in some cases by pallor +and perspiration. + +It need hardly be said that we should do all in our power to prevent +these alarming and distressing attacks. Each seizure predisposes to a +repetition. In some children we notice that months and even years +after an attack of whooping-cough, a slight bronchial catarrh may be +sufficient to bring back the characteristic cough. In laryngismus in +the same way we may suppose that the reflex path is made easy and the +resistance lowered by constant use. Fortunately the spasms are not +usually difficult to control. Calcium bromide, in doses of from two to +four grains, according to age, three times daily, is generally +successful with or without the addition of chloral hydrate in small +doses. At the same time we must endeavour in every way possible to +keep the child calm, by paying close attention to nursery management. +The child with spasmophilia is as a rule excitable and easily upset, +and although calcium bromide is a drug which offers powerful aid it is +not able to achieve its effect unless we are able at the same time to +guarantee a reasonable immunity from emotional upsets. It is for this +reason that I have included some description of laryngismus, although +its origin is undoubtedly very different from that of the other +disorders of conduct which we have examined. + + +MIGRAINE AND CYCLIC VOMITING + +The aetiology of cyclic or periodic vomiting in childhood is not yet +completely understood. We do not know how far it is dependent upon +disturbance of the liver, and it is still disputed whether the +acidosis which accompanies it is the cause or the result of the +profuse vomiting. Into these difficult questions we need not at the +moment enter. It is enough in the present connection to recognise that +the great majority of children who suffer from cyclic vomiting are +sensitive, excitable, and nervous, and that every one is agreed that +the nervous system is intimately concerned in its causation. + +A close association between cyclic vomiting in children and that form +of periodic headache known as migraine has often been observed. It is +sometimes found that one or both parents of a child with cyclic +vomiting suffer habitually from migraine. In a few instances the one +condition has been observed to be gradually replaced by the other, the +child with cyclic vomiting becoming in adult life a sufferer from +migraine. There is indeed much which is common to the two conditions. +The periodic nature of the seizure, often following a time when the +general health and vigour appear to have been at their optimum, the +extreme prostration, and the comparatively sudden recovery are found +in both. In the cyclic vomiting of children, it is true, little +complaint is made of headache, the visual aura is absent, and the +vomiting is invariably the most prominent symptom. + +Cyclic vomiting seldom occurs before the fourth year. It is +characterised by sudden profuse and persistent vomiting and by very +great prostration. All food, it may be even water, is promptly +rejected. The vomited matter is generally stained with bile; +occasionally the violence of the vomiting causes haematemesis. In many +cases the temperature is raised; sometimes it may be as high as 103 deg. +F. The duration of an attack varies. In most cases it does not last +longer than forty-eight hours. On the other hand, attacks lasting as +long as a week are by no means unknown. Within a short time of the +onset the urine may be found to contain acetone bodies, the breath may +smell distinctly of acetone, and the child may become torpid and +drowsy or agitated and restless. At times there may be exaggerated and +deepened respiratory movements--the so-called air hunger. In many +cases, however, otherwise characteristic, these more severe +manifestations are absent or but little apparent. Recovery is usually +rapid and complete. The child asks for food, which is retained. A +fatal ending is very rare, though not unknown. The frequency of +attacks is very various. Sometimes months or even years may elapse +between successive seizures; in other cases a fortnightly or monthly +rhythm establishes itself. + +It is clear that both the frequency and the severity of the attacks +are much influenced by the general state of the child's health. Like +migraine, cyclic vomiting appears to be a symptom of nervous +exhaustion. It affects, for the most part, children who are +intellectually alert, impressionable, and forward for their age, and +who, when well, throw themselves into work or play with a great +expenditure of nervous energy. Often their physical development is +unsatisfactory, and we must set ourselves to correct this as the first +step in prevention. It is highly important that children suffering in +this way should have free opportunities for exercise in the open +country, and that all the excretory organs--the skin, kidneys, and +bowels--should be acting freely and efficiently. The child should live +a life of ordered routine. Sleep should be sound and sufficient in +amount. The diet must not exceed the strict physiological needs. Many +of these children appear to have a lowered tolerance for fats of all +sorts, and it may be necessary to limit strictly the consumption of +milk, cream, butter, and so forth. A daily administration of a small +dose of alkali by the mouth is credited with preventing attacks. In +the present connection, however, we shall not do wrong to emphasise +the part played by the nervous system in the production of the +attacks. In all cases of cyclic vomiting it should be our endeavour to +recognise and remove the elements in the daily life of the child which +are proving too exhausting. + +UNEXPLAINED PYREXIA + +In nervous children we sometimes meet with inexplicable rises of +temperature. The pyrexia may have the same periodic character as that +just noted in cases of cyclic vomiting. At intervals of three, four, +or five weeks there may be a rise of temperature to 103 deg. F., or even +higher, which may last for two or three days before subsiding. In +other cases the chart shows a slight persistent rise over many weeks +or months. That in nervous children the temperature may be very +considerably elevated without our being able to detect much that is +amiss does not of course make it any the less necessary to be careful +to exclude organic disease. Pyelitis, tuberculosis, and latent otitis +media occur with nervous children as with others and must not be +overlooked. If, however, organic disease can be excluded, and if the +pyrexia is the only circumstance which prevents the decision that the +child is well and should be treated as well, then the thermometer may +be overruled and the pyrexia neglected. + + + + +CHAPTER VI + +ENURESIS + + +I have dealt in previous chapters with certain common disorders of +conduct in childhood, which show clearly their origin in the +apprehensions of the grown-up people who have charge of the children, +and in the unwise suggestions which they convey to them. The same +forces are at work in the production of enuresis, or bed wetting, +although the matter is here often complicated by the development later +on of a sense of shame and unhappiness in the child. There comes a +time when the child passionately desires to regain control and is +miserable about her failure, until the concentration of her thoughts +on the subject becomes a veritable obsession. Every night she goes to +bed with this only in her mind. Every night she falls asleep, +miserably aware that she will wake to find the bed wetted. The +suggestion impressed in the first place on the mind of the tiny child +by injudicious management has become fixed by the growing sense of +shame and the complete loss of self-confidence. + +It is usually taught that a great variety of causes is concerned in +producing enuresis. It is said to be due to a partial asphyxia during +sleep from adenoid vegetation. It is said to be caused by phimosis, +and to be cured by circumcision. It is said that the urine is often +too acid and so irritating that the bladder refuses to retain it for +the usual length of time. It is said that enuresis may be due to a +deficiency of the thyroid secretion, and that it can be cured by +thyroid extract. Such a number of rival causes may make us hesitate to +accept the claims of any one of them. Certainly I have not been able +to satisfy myself that any one of these conditions exercises any +influence at all or is commonly present in cases of enuresis. I think +that if we examine a large number of cases of bed wetting in children +we can come to no other conclusion than that the cause of the trouble +is due to just such a pervasion of suggestion as we have been +considering above. + +There are certain points in the behaviour of a child with enuresis +which seem to point to this conclusion. + +_(a)_ In the first place, the trouble is seldom serious or very well +developed in early childhood, and the reason for this, I take it, is +that an occasional lapse in a child of perhaps two or three years of +age is usually treated lightly and in the proper spirit of tolerance. +It is only with children a little older that nurses and parents become +distressed and begin unwittingly by urging the child to present the +suggestion to her mind, that the bed may or will be wetted. Hence the +usual history is that control was partially acquired in the second +year, but that, instead of later becoming complete, relapses began to +be more frequent, and that since that time all that can be done seems +only to make matters worse. + +_(b)_ In the second place, the influence of suggestion is shown by the +behaviour of the child when removed to a hospital for observation. It +is the invariable experience that the enuresis then promptly stops. In +hospital the attitude of those around the child is entirely different. +She has the comfortable and consoling feeling that in wetting the bed +she is doing exactly what is expected of her. There is even a feeling +that otherwise she is showing herself to be something of a fraud, and +that she has then been admitted to the hospital on false pretences. +Hence, perhaps for the first time in many years, the child is free +from the obsession, and the bed is not wetted. + +_(c)_ In the third place, it is easy to recognise in the history of +many of the cases, the ill-effects of circumstances which add new +force to the fear of failure or shake the confidence in the control +which had been regained. Thus a boy, an only child, who had suffered +from enuresis till his seventh year, had regained complete control +till his eleventh year, when he went to school. In his dormitory at +school was a boy who had enuresis, and who was being fined and +punished by the schoolmaster. The enuresis at once reappeared and +continued unchecked so long as he was at school. As might be expected, +school life is very inimical to cure, unless the trouble can be kept +from the knowledge of the other boys. Anything which directly +increases the nervousness of the child--an illness, for example, with +loss of weight and failure of nutrition, or some mental stress, such +as the approach of an examination--is apt to accentuate the enuresis. + +_(d)_ In the fourth place, the incontinence sometimes spreads to the +daytime, and the child is wet both by day and night. Further, in bad +cases it is not uncommon to find incontinence of faeces making its +appearance also. These extensions of the fault only take place when +the management continues to be very faulty, when the grown-up people +around them are more than usually distressed and pessimistic, and have +redoubled their expostulations and appeals. + +Now these peculiarities of enuresis seem to me only explicable if we +assume that the want of control is due to auto-suggestion, dependent +at the beginning on the unwise attitude adopted towards the fault by +the nurses and parents, and later kept up by the sense of shame and +the mental distress involved. + +The forms of treatment which have been recommended from time to time +are, as might be expected, very numerous. + +_(a) Operative._--(i) Removal of tonsils and adenoids, (ii) +Circumcision. + +_(b) Manipulative._--(i) Injection of saline solution under the skin +in the perineal and pubic regions, with object of lowering the +excitability of the bladder by counter-irritation. (ii) Gradual +distension of the bladder by hydrostatic pressure, (iii) Tilting the +foot of the bed so as to throw the urine to the fundus of the +bladder, in order to protect the sensitive trigone from irritation. + +_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the +child at intervals during the night by an alarm clock or otherwise. +(iii) Rewards and punishments. + +_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract. + +_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic +suggestion. + +I do not think that any single one of these various forms of treatment +outlined under the first four heads has any effect other than to aid +the suggestion of cure which we proffer in adopting it. Removal of +tonsils and adenoid vegetations might conceivably cure an enuresis +which is nocturnal, it cannot account for an incontinence which +spreads to the day. We might believe that to distend the bladder by +hydrostatic pressure was a cure for incontinence of urine, and that it +acted by removing the local cause,--the smallness and contraction of +the bladder,--were it not that the loss of control is so apt to spread +to the rectum as well. There is no evidence that the urine is +peculiarly irritating. Indeed, such evidence as we have goes to show +that, as in some other neuroses, the urine in enuresis is unduly +copious, and of very low specific gravity. Incidentally, we have in +this polyuria a further argument against the view recently advanced +that a small and contracted irritable bladder is the cause of +enuresis. We do, of course, meet with cases of irritable bladder often +enough, but the complaint is then not of incontinence, but always of +the discomfort of having to rise so frequently for micturition. + +To deprive the child of fluid, to wake her many times at night, to +tilt the foot of the bed, are devices which may help in the hands of +some one who is confident of his ability to cure the condition and can +communicate the confidence to the child. Carried out hopelessly and +pessimistically by a tired and exasperated mother, they are well +calculated to strengthen the hold which the obsession has on the +child, so that often we meet with a mother who rightly enough +maintains that the more she wakes the child, the oftener the bed is +wet, till she wonders where it all comes from. + +The treatment of enuresis to be successful must be conducted through +and by means of the grown-up persons who have the control of the +children. To stop the development of enuresis in early infancy we must +intervene to prevent the concentration of the child's mind on the +difficulty. During the time when control is ordinarily developed, in +the second and third year, judicious management of the child is +essential. The emphasis should be laid upon successes, not upon +failures. For every child his reputation will sway in the balance for +a time. He must be helped and encouraged to self-confidence, not +rendered diffident or self-conscious. + +If the case is well established before it comes under our notice, the +mother, the nurse, the schoolmaster, or whoever is responsible for the +child's management, must understand clearly the nature of the trouble. +The suggestion acting on the child's mind must be altered, and +self-confidence restored. The child must learn to see that the thing +is not so desperately tragic. He should be told that the trouble +always gets well, and that it only goes on now because he is worried +about it and keeps thinking of it. If the whole environment of the +child is bad, so that such a change of suggestion is not possible, and +if enuresis is but one of many symptoms of mental or moral +instability, it may be necessary to remove the child and place him +under the influence of some one else. Sometimes the prescription of a +rubber urinal, which the child can slip on at night, is directly +curative. A public school boy, who was about to be sent away from +school for this failing, fortified by the possession of this +apparatus, wrote six months later to say that he knew now that it must +be all worry that caused the trouble, because with the urinal in +position he had not once had the incontinence. + +In inveterate cases hypnotic suggestion is always, I think, +successful. It is obvious, however, that in many cases there are +objections to its use. Often enuresis is evidence that the child's +home environment has been at fault, and that his mental and moral +development has been retarded. It is the management which must be +modified or the home, if necessary, changed. Hypnotic suggestion will +make this one symptom disappear promptly enough, but it will rather +perpetuate than combat the cause--that undue susceptibility to +suggestion, which is characteristic alike of the little child and of +many older neuropathic persons. + + + + +CHAPTER VII + +TOYS, BOOKS, AND AMUSEMENTS + + +Any one who has an opportunity of watching little children must have +observed that they are happiest and most contented when playing alone. +The education of the little child is carried on by means of games and +toys. Handling the various objects which we give him, imparting +movement to them, transferring them from hand to hand and from one +situation to another, he learns dexterity and precision of movement, +and in the process hand and brain grow in power. When at play, his +whole energies should be absorbed to the exclusion of everything else. +He will often be oblivious to everything that is going on around him, +intent only on the purpose of the moment. In order to permit this +fervour of self-education it is necessary that the child should be +accustomed to playing alone, and it is well, if only for convenience' +sake, that he should be accustomed to playing in a room by himself. +Something is wrong if the child cannot be left for a few moments +without breaking into tears or displaying bad temper. Engrossed in his +own tasks, he should be content to leave his nurse to move in and out +of the room without protest. If this fault has appeared and the child +cannot be left alone, our whole educational system is undermined, and +play will be profitless and over-exciting, because it demands the +constant participation of grown-up people. As a preliminary to all +improvement in the management of a nervous child, we must see to it +that he becomes accustomed to being alone. We must so arrange his +nursery that he can do no damage to himself. Scissors and matches must +not be left lying about, and a fireguard must be fixed in position so +that it cannot be disturbed. Then, disregarding his protests, the +nurse must leave him to himself, at first only for a moment or two, +re-entering the room in a matter-of-fact way without speaking to him, +and again leaving it. Soon he will learn that a temporary separation +does not mean that we have abandoned him for all time. Then the period +of absence can be gradually lengthened till all difficulty disappears. +Once his attention is removed from the grown-up people who mean so +much to him, his natural impulse to explore and experiment with his +playthings will show itself. Those toys are best which are neither +elaborate nor expensive. For a little child a small box containing a +miscellaneous collection of wooden or metal objects, none of them +small enough to be in danger of being swallowed, forms the material +for which his soul craves. Everything else in the room may be out of +his reach. A dozen times he will empty the box and then replace each +object in turn. He will arrange them in every possible combination, +and then sweep the whole away to start afresh. + +At eighteen months of age observation and imitative capacity will +have made more complex pursuits possible. As a rule the objects which +are most prized and which have most educative value are those which +lend themselves best to the actions with which alone the child is +familiar. Hence the supreme importance of the doll and the doll's +perambulator. The doll will be treated exactly as the child is treated +by the nurse. It will be washed, and dressed, and weighed, and put to +bed in faithful reproduction of what the child has daily experienced. +Dusting, and sweeping, and laying the table will be exactly copied. If +a child has no opportunity of being familiar with horses, if he has +not seen them fed, and watered, and groomed, and harnessed, he may not +find any great satisfaction in a toy horse, or pay much attention to +it, no matter how costly or realistic it may be. + +In the third year more precise tasks, such as stringing beads, +drawing, and painting, will play their part, while at the same time +the increased imaginative powers will give attraction to toy soldiers +or a toy tea-service. Playing at shop, robbers, and rafts are +developments of still later growth. In the child's games we recognise +the instinct of imitation--playing with dolls, sweeping and dusting, +playing at shop or visitors; the instinct of constructiveness--making +mud pies and sand castles, drawing or whittling a stick; and the +instinct of experiment--letting objects fall, rattling, hammering, +taking to pieces. All this activity must be encouraged, never unduly +repressed or destroyed. But whatever form it takes, the bulk of the +play must be carried on without the intervention of grown-up persons, +or it will lose its educative value and prove too exacting. If +grown-up people attempt to take part, the child will lose interest in +the play and turn his attention to them. + +Children differ very much in their attitude towards books. One child +quite early in the second year will be happy poring over picture +books, while another will seldom glance at the contents and finds +pleasure only in turning over the pages, opening and shutting them, +and carrying them from place to place. Such differences are natural +enough and foreshadow perhaps the permanent characteristics that +divide men and women, and produce in later life men of thought and men +of action, women who are Marthas and women who are Marys. +Nevertheless, we should bear in mind that there is danger in a +training that is too one sided, and that books and toys have both +their part to play in developing the powers of the child. All the +activities of the child should be used in as varied a way as possible. +The eye is but one doorway to knowledge and understanding, the ear is +another, the hand a third. + +From pictures an imaginative child will derive very strong +impressions, and mothers should be careful in their choice. It is +foolish to confuse the growth of aesthetic perceptions by presenting +children with books which depict children as grotesquely ugly beings +with goggle eyes and heads like rubber balls. Children love animals +and endow them with all their own reasoning attributes, and in +stories of the home life of rabbits, and bears, and squirrels they +take a pure delight. Books of the "Struwwelpeter" type are less to be +recommended. The faults which they are intended to eradicate become +peculiarly attractive from much familiarity. A little boy of two and a +half who resolutely refused all food for some days was in the end +detected to be playing the part of that Augustus, once so chubby and +fat, who reduced himself to a skeleton, saying, "Take the nasty soup +away; I don't want any soup to-day." Tales of naughty children who +meet with a distressing fate may either frighten the child unduly, or +else produce in a child of inquiring mind the desire to brave his fate +and put the matter to the test. Pictures should not be terrifying or +horrible. Ogres devouring children are out of place as subjects for +pictures and may cause night-terrors. + +Children should be taught to be careful of books and toys. The +indestructible book, generally falsely so called, is often responsible +for the immediate dissolution of all others less protected which come +to hand. The sympathy which little children have with the sufferings +of all inanimate objects and their habit of endowing them with their +own sensations may be made of use in teaching them care and +gentleness. They are naturally prone to sympathise with the doll that +has been crushed or the book that has been torn. They will learn very +easily to be kind to a pet animal and to be solicitous for its +feelings, and the lesson so learnt will be applied to inanimate +objects as well. + +There is, however, another side to the question. It is true that if +the child is not to be over-stimulated upon the psychical side, we +must see to it that his play, for the most part, is not dependent upon +the participation of grown-up persons. In practice this excessive +stimulation is the common fault with which we meet. There are few +children in well-to-do homes, with loving mothers and devoted nurses, +who suffer from too little mothering and nursing. Too many show signs +of too much. To observe the opposite fault we must seek the infants +and children who for a long time are inmates of institutions, +orphanages, infirmaries, hospitals, and so forth. In such surroundings +the mental life of the child may languish. His physical wants are +cared for, but there the matter ends. In a rigid routine he is washed +and fed, but he may not be talked to or played with or stimulated in +any way. His day is spent passively lying in his cot, unnoticed and +unnoticing. I have seen a poor child of three years just released from +such a life, and after eighteen months returned to his mother, unable +to talk and almost unable to walk, crying pitifully at the novelty and +strangeness of the noisy life to which he had returned, worried by +contact with the other children, and without any desire or power to +occupy himself in the home. For an hour in the day mothers may devote +themselves wholeheartedly to the children, and if they set them +romping till they are tired out, so much the better. In the garden or +in an airy room with the windows open, a game with a ball or a toy +balloon, or a game of hide-and-seek, will be all to the good, and the +children may climb and be rolled over and swung about to their heart's +content. With an only child, especially with a child whose home is in +town, and whose outings are limited to a sedate airing in the park, +such free play is especially necessary. It may help more than anything +else to quiet restless minds and tempers that are on edge all day long +from excessive repression. + +On the other hand, those forms of entertainment which are known as +"children's parties" are generally fruitful of ill results, at any +rate with nervous and highly-strung children. Sometimes they entail a +postponement of the usual bedtime, and nearly always they involve +over-heated and crowded rooms. Perverse custom has decreed that these +gatherings shall take place most commonly in the winter, when dark and +cold add nothing to the pleasure and a great deal to the risk of +infection which must always attend the crowding of susceptible +children together in a confined space with faulty ventilation. There +is clearly on the score of health much less objection to summer garden +parties for children, but these for some reason are less the vogue. As +a rule parties are not enjoyed by nervous children. There is intense +excitement in anticipation, and when at length the moment arrives, +there is apt to be disillusion. Either the excitement of the child may +pass all bounds and end in tears and so-called naughtiness, or the +unfamiliar surroundings may leave him distrait with a strange sense of +unreality and unhappiness. It is not always fair to blame the want of +wisdom in his hostess's choice of eatables, if the excited and +overstimulated child fails in the work of digestion and returns to the +nursery to suffer the reaction, with pains and much sickness. + +The same arguments may be urged against taking little children to the +theatre. The nerve strain is apt to be out of proportion to the +enjoyment gained. If children must go to theatres and parties, the +treat should be kept secret from them until the moment of its +realisation, in order that the period of mental excitement should be +contracted as much as possible, and grown-up people should be advised +to treat the whole expedition in a matter-of-fact sort of way that +does nothing to add to the excitement or increase the risk of +subsequent disillusion. + + + + +CHAPTER VIII + +NERVOUSNESS IN EARLY INFANCY + + +We may now pass back to consider the nervous system of the child in +infancy. There, too, from the moment of birth there are clearly-marked +differences between individuals. The newborn baby has a personality of +his own, and mothers will note with astonishment and delight how +strongly marked variations in conduct and behaviour may be from the +first. One baby is pleased and contented, another is fidgety, +restless, and enterprising. At birth the baby wakes from his long +sleep to find his environment completely changed. Within the uterus he +lies in unconsciousness because no ordinary stimulus from the outer +world can reach him to exert its effect. He lies immersed in fluid, +which, obeying the laws of physics, exercises a pressure which is +uniformly distributed over all points of his body. No sound reaches +him, and no light. After birth all this is suddenly changed. The sense +of new points of pressure breaks in upon his consciousness. Cold air +strikes upon his skin. Loud sounds and bright lights evoke a +characteristic response. A placid child who inherits a relatively +obtuse nervous organisation will be but little upset by this sudden +and radical change in the nature of his environment. His brain is +readily but healthily tired by the new sensations which stream in from +all sides, and he falls straight away into a sleep from which he +rouses himself at intervals only under the impulse of the new +sensation of hunger. + +Babies of nervous inheritance, on the other hand, will show clearly by +the violence of the response provoked that their nervous system is +easily stimulated and exhausted. They will wriggle and squirm for +hours together, emitting the same constant reflex cry. The whole body +will start convulsively at a sudden touch or a loud sound which would +evoke no response from a more stolid infant. The sleeplessness and +crying exhaust the baby, rendering the nervous system more and more +irritable, while the sensation of hunger which is delayed in other +children by twelve hours or more of deep sleep appears early and is of +extreme intensity. We must see to it that sense stimuli are reduced to +the lowest possible level. True, we cannot again restore the child to +a bath of warm fluid, of the same temperature as his body, where he +can be free from irksome pressure and from all sensations of sound and +light, but we can so arrange matters that he is not disturbed by loud +sounds and bright lights, and that he is not moved more than is +necessary. Sudden unexpected movements are especially harmful. Jogging +him up and down, patting him on the back, expostulation, and +entreaties are all out of place and do all the harm in the world. The +first bath should be as expeditious as possible, and above all the +baby must not be chilled by tedious exposure. Cold irritates his +nervous system more than anything else, unless it be excessive warmth. +In preserving the proper temperature so that we do not render the +child restless by excess of heat or by excess of cold, we +too-civilised people have made our own difficulties. We have +exaggerated the completeness of the sudden separation of mother and +child which nature decrees. It is the function of all mother animals +to approximate the unstable temperature of the newly born to their own +by the close contact of their bodies, which provide just the proper +heat. Labour is nowadays so complicated and exhausting a process for +mothers that, all things considered, we are wise in completing the +separation of mother and child and in removing the baby to his own +cot. But the difficulty remains, and we must arrange that any +artificial heating needed is constant and of proper degree. + +If the baby is very restless and irritable, too wide awake and too +conscious of his surroundings, the all-important task of getting him +to the breast and getting him to draw the milk into the breast is apt +to be difficult. His sucking is a purely reflex and involuntary act. +It can be produced by anything which gently presses down the tongue, +and a finger placed in the proper position will provoke the movement +without the child's consciousness being aroused. The placid child +whose mind is at rest will suck well and strongly. If, on the other +hand, the brain is too much stimulated and the child is restless and +irritable, the reflex act of suction is inhibited, and it is a +difficult matter to get the child to the breast. He is too eager, +mouthing, and gulping, and spluttering. Or sometimes his mental +sufferings seem too much for his appetite, and though wide awake and +crying loudly, he refuses to grasp the nipple, turning his head away +and wriggling blindly hither and thither. This effect of mental unrest +on the newborn infant is often disastrous, because it is one of the +common causes of the failure of women to nurse their children. This is +not the place to sketch in detail a scheme for the proper technique of +breast nursing, a matter which is much misunderstood at the present +day. It will be enough shortly to say that an efficient supply of milk +depends upon the complete and regular emptying of the breast. The +breasts of all mothers will secrete milk if strong and vigorous +suction is applied to the nipple by the child. If anything interferes +with suction, the milk does not appear or, if it has appeared, it +rapidly declines in amount. The mother's part is to a great extent a +passive one, provided that she can supply one essential--a nipple that +is large enough for the child to grasp properly. Within wide limits +what the mother eats or drinks, whether she be robust or whether she +has always been something of an invalid, matters not at all. A frail +woman may naturally not be able to stand the strain of nursing for +many months, but that is not here the point in question. We are +dealing only with the establishment of lactation and with the milk +supply of the early days and weeks which is of such vital importance +for the child. If the mother is ill, if, for example, she has +consumption, we may separate her from the child in the interests of +both; but if this is not done, she will continue to secrete milk for a +time as readily as if she were in perfect health, and the breasts of +many a dying woman are to be seen full of milk. Mothers are too apt to +attribute the disappointment of a complete failure to nurse to some +weakness or want of robustness in their own health. This is never the +reason of the failure, and the fault, if the mother has a well-formed +nipple, is generally to be found in some disturbance in the child. +Prematurity, with extreme somnolence, breathlessness from respiratory +disease, nasal catarrh, which hinders breathing through the nose, +infections of all sorts, are common causes of this failure to suck +effectively. But perhaps the most common cause of all is the +inhibition from nervous unrest of that reflex act of sucking which +works so well in the placid and quiet child. It is a point to which +too little attention is paid, and mothers and the books which mothers +read commonly neglect the nervous system of the child and devote +themselves to such considerations as the relative merits of two-hourly +and four-hourly feedings--important points in their way, but less +important than this. + +The matter is complicated in two other ways. In the first place, the +nervous baby, just because he is so active and wakeful and restless, +is apt rapidly to lose weight and to have an increased need for food. +The restlessness is generally attributed to hunger, and this is true, +because hunger is soon added to the other sensations from which he +suffers, and like them is unduly acute. It is difficult not to give +way and to provide artificial food from the bottle. Yet if we do so we +must face the fact that these restless little mortals are quicker to +form habits than most, and once they have tasted a bottle that flows +easily without hard suction, they will often obstinately refuse the +ungrateful task of sucking at a breast which has not yet begun to +secrete readily. The suction that is devoted to the bottle is removed +from the breast, and the natural delay in the coming in of the milk is +increased indefinitely. At the worst, the supply of milk fails almost +at its first appearance. We must devote our attention to quieting the +nervous unrest by removing all unnecessary sensory stimulation from +the baby. He must be in a warm cot, in a warm, well-aired, darkened, +and silent room, and the necessary handling must be reduced to a +minimum. Sometimes sound sleep will come for the first time if he is +placed gently in his mother's bed, close to her warm body. If he is +apt to bungle at the breast from eagerness and restlessness, it is not +wise always to choose the moment when he has roused himself into a +passion of crying to attempt the difficult task. So far as is possible +he should be carried to the breast when he is drowsy and sleepy, not +when he is crying furiously, and then the reflex sucking act may +proceed undisturbed. + +In the second place, we must guard against the ill effect which the +ceaseless crying of these nervous babies has upon the mother. She may +be so exhausted by the labour that her nerves are all on edge, and she +grows apprehensive and frightened over all manner of little things. +The tired mother is apt to fear that she will have no milk, and her +agitation grows with each failure on the part of the child. Now the +first secretion of milk is very closely dependent upon the nervous +system of the mother. We have said that within wide limits her +physical condition is of less importance, but her peace of mind is +essential. And so it is wise for some part of the day to keep the +nervous baby out of hearing of the mother, and so far as possible to +choose moments when the child is quiet to put him to the breast. A +nurse with a confident, hopeful manner will effect most; a fussy, +over-anxious, or despondent attitude will do untold harm. We shall +sometimes fail if the nervous unrest is very obstinate either in +mother or in child, but we shall fail less often if we diagnose the +cause correctly in the cases we are considering. Lastly, it is +possible to control the condition in both mother and child by the +careful use of bromide or chloral. + +It is not, of course, suggested that these drugs should be given +freely or as a routine to every hungry baby wailing for the breast, or +that we can hope to combat or ward off an inherited neuropathy by a +few doses of a sedative. There are, however, not a few babies in whom +there develops soon after birth a sort of vicious circle. They can +suck efficiently and digest without pain only when they sleep soundly. +If they are put to the breast after much crying and restlessness, +each meal is followed by flatulence, colic, and renewed crying. The +only effective treatment is to secure sleep and to carry a slumbering +or drowsy infant to the breast. Then the sucking reflex comes to its +own again, the breast is drained steadily and well, and digestion +proceeds thereafter without disturbance and during a further spell of +sleep. Two or three times in the day we may be forced, as meal-time +approaches, to cut short the restlessness of the child by giving a +teaspoonful of the following mixture: + +Pot. brom., grs. ii. [2 grains] + +Chloral hydrate, gr. i. [1 grain] + +Syrup, M x. [10 minims] + +Aq. menth. pip., ad 3 i. [1 dram] + +After this has been taken the child should be laid down for a quarter +of an hour until soundly asleep. Then very gently he can be carried to +his mother and the nipple inserted. If in this way a few days of sound +sleep and less disturbed digestion can be secured, the difficulty will +in most cases permanently be overcome. The steadier suction and more +efficient emptying of the breast will promote a freer flow of milk, +and the deeper and more prolonged sleep will lower greatly the needs +of the child for food. Most of the babies who show this fault are +thin, meagre, and fidgety, and with some increase of muscular tone. +The head is held up well, the limbs are stiff, the hands clenched, the +abdomen retracted, with the outline of the recti muscles unusually +prominent. If we can relax this exaggerated state of nervous tension, +if we can help them to become fatter and to put on weight, the +dyspepsia will disappear with the other symptoms. + +It is a question still to be answered whether the rare conditions of +pyloric spasm and pyloric hypertrophic stenosis are not further +developments of the same disturbance. Certainly these grave +complications appear most commonly in infants with a pronounced +nervous inheritance, and, as might be expected, they are more commonly +found in private practice than among the hospital classes. + +In passing, we may note that there are babies who exhibit the opposite +fault, and in whom the contrary regimen must be instituted. Premature +children, children born in a very poor state of nutrition, and +children born with great difficulty, so that they are exhausted by the +violence of their passage into the world, are apt to show the opposite +fault of extreme somnolence. They are so little stimulated by their +surroundings, and they sleep so profoundly, that the sucking reflex is +not aroused. Put to the breast they continue to slumber, or after a +few half-hearted sucking movements relapse into sleep. We must rouse +such children by moving them about and stirring them to wakefulness +before we put them to the breast. + +Once the child has been got to the breast, once the milk has become +firmly established, we have overcome the first great difficulty which +besets us in the management of nervous little babies, but it is by no +means the last. Restlessness and continual crying must be combated or +digestion suffers, and may show itself in a peculiar form of explosive +vomiting, which betokens the reflex excitability and unrest of the +stomach. + +The sense of taste is as acute as all other sensations. If the child +is bottle-fed, the slightest change in diet is resented because of the +unfamiliar taste, and the whole may promptly be rejected. The tendency +to dyspeptic symptoms is apt to lead to much unwise changing of the +diet, and everything tried falls in turn into disrepute, until perhaps +all rational diets are abandoned, and some mixture of very faulty +construction, because of its temporary or accidental success, becomes +permanently adopted--a mixture perhaps so deficient in some necessary +constituent that, if it is persisted with, permanent damage to the +growth of the child results. We must pay less attention to changes of +diet and explore our management of the child to try and find how we +can make his environment more restful. + +It is wise to accustom a nervous child from a very early age to take a +little water or fruit juice from a spoon every day. Otherwise when +breast-feeding or bottle-feeding is abandoned one may meet with the +most formidable resistance. Infants of a few months can be easily +taught; the resistance of a child of nine months or a year may be +difficult to overcome. The difficulty of weaning from the breast +recurs with great constancy in nervous children. By this time the +influence of environment has become clearly apparent. The child is +often enough already master of the situation, and is conscious of his +power. Such children will sometimes prefer to starve for days +together, obstinately opposing all attempts to get them to drink from +a spoon, a cup, or even a bottle. When this happens, sometimes the +only effective way is to change the environment and to send the baby +to a grandmother or an aunt, where in new surroundings and with new +attendants the resistance which was so strong at home may completely +disappear. When weaning is resented, and difficulties of this sort +arise, it is clear that the mother, whose breast is close at hand, is +at a great disadvantage in combating the child's opposition. + +For nervous infants, alas! broken sleep is the rule. What, then, is to +be done? It is astonishing to me that any one who has studied the +behaviour of only a few of these nervous and restless infants should +uphold the teaching that the crying of the young infant is a bad +habit, and that the mother who is truly wise must neglect the cry and +leave him to learn the uselessness of his appeals. It is true that the +youngest child readily contracts habits good or bad. Either he will +learn the habit of sleep or the habit of crying. Mercifully the +inclination of the majority is towards sleep. But to encourage habits +of restlessness and crying there is no surer way than to follow this +bad advice and to permit the child to cry till he is utterly exhausted +in body and in mind. It is unwise _always_ to rock a baby to sleep; it +is also unwise to allow him to scream himself into a state of +hysteria. A quiet, darkened room, the steady pressure of the mother's +hand in some rhythmical movement, will often quiet an incipient +storm. The longer he cries, the more trouble it is to soothe him. +Sleep provokes sleep, so that often we find restlessness and sound +sleep alternating in a sort of cycle, a good week perhaps following a +bad one. The nurse who is quick to cut short a storm of crying and to +soothe the child again to sleep is helping him to form habits of +sleep. The nurse who leaves him to cry, believing that in time he will +of his own accord recognise the futility of his behaviour, is making +him form habits of crying. A rigid routine in sleep is a good thing, +but the routine belongs to the baby, not to the nurse. The child must +be educated to sleep, not taught to cry. A baby has but little power +of altering his position when it becomes strained or uncomfortable. He +cannot turn over and nestle down into a new posture. If we watch him +wake, the first stirring may be very gradual, and in a moment he may +fall again to sleep. A few minutes later he stirs again more strongly, +and is wider awake and for longer. It may only be after a third +waking, by a summation of stimuli, that he is finally roused and +breaks into loud crying. The nurse who is on the watch, who, sleeping +beside him, wakes at the slightest sound and is quick to turn him over +and settle him into a new position of rest, will probably report in +the morning that the baby has had a good night. The nurse who lets the +child grow wide awake and start crying loudly, will spend perhaps many +hours before quiet is again restored. Of the voluntary, purposive +crying of infants a little older I am not here speaking. Infants in +the second six months are quite capable of establishing a "Tyranny of +Tears" and feeling their power. Fortunately it requires no great +experience to distinguish one from the other, and to adopt for each +the appropriate treatment. + +Again, in elementary teaching upon the management of infants stress is +laid, rightly enough, upon the importance of regularity in the times +of feeding, and on the observance in this respect also of a very +strict routine. But in the case of the very nervous infant a certain +latitude should be allowed to an experienced nurse or mother. We may +wreck everything by a blind adhesion to a too rigid scheme, which may +demand that we leave the child to scream for an hour before his meal, +or that, when at length he has fallen into a sound sleep after hours +of wakefulness, we should proceed to wake him. + +Symptoms of dyspepsia which are due to continued nervous excitement +demand treatment which is very different from that which would be +appropriate to dyspepsia which is due to other causes, such as +overfeeding or unsuitable feeding. The temporary restriction of food, +which is commonly ordered in dyspepsia from these causes, is very +badly supported by the nervous infant. Hunger invariably increases the +unrest, and the unrest increases the dyspepsia. + +The difficulties of managing a nervous infant are very real, and call +for the most exemplary patience on the part of the mother and the +clearest insight into the nature of the disturbance. + + + + +CHAPTER IX + +MANAGEMENT IN LATER CHILDHOOD + + +In the early days in the nursery the actions of the infant, for the +most part, follow passively the traction exercised by nurses and +mothers, sometimes consciously, but more often unconsciously. We have +now to consider a period when the child becomes possessed of a driving +force of his own, and moves in this direction or that of his own +volition. In this new intellectual movement through life he will not +avoid tumbles. He will feel the restraints of his environment pressing +upon him on all sides, and he will often come violently in contact +with rigid rules and conventions to which he must learn to yield. From +time to time we read in the papers of some terrible accident in a +picture-palace, or in a theatre. Although there has been no fire, +there has been a cry of fire, and in the panic which ensues lives are +lost from the crowding and crushing. Yet all the time the doors have +stood wide open, and through them an orderly exit might have been +conducted had reason not given place to unreason. It is the task of +those responsible for the children's education to guide them without +wild struggling along the paths of well-regulated conduct towards the +desired goal, influenced not by the emotions of the moment, but only +by reason and a sense of right; not ignorant of the difficulties to be +met, but practised and equipped to overcome them. + +It is easy thus to state in general terms the objects of education, +and the need for discipline. To apply these principles to the +individual is a task, the immeasurable difficulty of which we are only +beginning to appreciate with the failure of thirty years of compulsory +education before us. A recent writer[2] gives it as his opinion that +the aim of education is to equip a child with ideals, and that this +task should not be difficult, because the lower savages successfully +subject all the members of their tribe to the most ruthless +discipline. Their lives, he says, "are lived in fear, in restraint, in +submission, in suffering, subject to galling, unreasoning, +unnecessary, arbitrary prohibitions and taboos, and to customary +duties equally galling, unreasoning, unnecessary, and arbitrary. They +endure painful mutilations, they submit to painful sacrifices.... How +are these wild, unstable, wayward, impulsive, passionate natures +brought to submit to such a rigorous and cruel discipline? By +education; by the inculcation from infancy of these ideals. In these +ideals they have been brought up, and to them they cling with the +utmost tenacity." One might as well contend that it was easy to teach +all men to live the self-denying life of earnest Christians because +some savage tribe was successful in maintaining among its members a +universal and orthodox worship of idols. The ideals set before the +child are too high and too complex to be inculcated by physical force, +or even by force of public opinion. A rigid discipline, with many +stripes and with terrible threats of a still worse punishment in the +world to come, was the almost invariable lot of children until the +last century was well advanced. Yet has this drastic treatment of +young children fulfilled its purpose? Were the men of fifty years ago +better conducted and more controlled than the men of to-day? In any +one family did a greater proportion turn out well? Is it not true that +at least among the educated classes the relaxation of nursery and +schoolroom discipline which the last fifty years has seen has been +justified by its results? Is it not true that the childhood of our +grandmothers was often lived "in fear, in restraint, in submission, in +suffering subject to galling, unreasoning, unnecessary, arbitrary +prohibitions and taboos, and to customary duties equally galling, +unreasoning, unnecessary, and arbitrary." And though perhaps the +grandmothers of most of us may not have been much the worse for all +this discipline, is it not true that of the little brothers who shared +the nursery with them a surprising number broke straightway into +dissipation when the parental restraints were removed? If we are to +teach a child to be gentle to the weak it is not wise to beat him. The +qualities which we wish him to possess are not more subtle than the +means by which we must aid him to their possession. + +[Footnote 2: _The Principles of Rational Education_, by Dr. C.A. +Mercier.] + +Education comprises physical, mental, and moral training. In earlier +times physical strength and the power to fight well, alone were prized +and were the chief objects to be gained in the education of youth. +Later, under the stress of intellectual competition for success in +life, mental acquirements have come to occupy the first place. We are +only now learning to lay emphasis upon the supreme need for moral +training. Not that it is possible to separate the sum of education +into its constituent parts, and to regard each as distinct from the +others. That many men of great intellectual activity, and many men +pre-eminent for their moral qualities have harboured a great brain or +a noble character in a weakly or deformed body, forms no argument to +disprove the general rule that a healthy, vigorous physique is the +only sure foundation upon which to build a highly developed intellect +and a stable temperament. In childhood the intimate connection between +vigour of mind and vigour of body is almost always clearly shown. A +child with rickets, unable to exercise his body in free play, as a +rule shows a flabbiness of mind in keeping with his useless muscles +and yielding bones. Such children talk late, are infantile in their +habits and ways of thought, and are more emotional and unstable than +healthy children of the same age. The connection between bodily +ailments and instability of nervous control is even more clearly seen +in the frequent combination of rheumatism and chorea. A very high +proportion of older children suffering from the graver neuroses, such +as chorea, syncopal attacks, phobias, tics, and so forth, show +defective physical development. Scoliosis, lordosis, knock-knee, flat +foot, pigeon chest, albuminuria, cold and cyanosed extremities, are +the rule rather than the exception. If the body of the child is +developed to the greatest perfection of which it is capable we shall +not often find a too sensitive nervous system. The boy of fine +physique may have many faults. He may be bad-tempered or untruthful or +selfish, but such faults as he has are as a rule more primitive in +type, more readily traced to their causes, and more easy to eradicate +than the faults which spring from that timidity, instability, and +moral flabbiness which has so often developed in the lax delicate +child reared softly in mind and body. + + +PHYSICAL TRAINING + +Children thrive best in the healthy open-air life of the country, and +if there is any tendency to nervous disturbances the need for this +becomes insistent. Physical training, further, includes the manual +education of the child. The system of child-training advocated by Dr. +Montessori is based upon the cultivation of tactile sensations and the +development of manual dexterity. Exercises such as she has devised +have an immediate effect in calming the nervous system and in changing +the restless or irritable child into a self-restrained and eager +worker. Lord Macaulay, whose phenomenal memory as a child has become +proverbial, was so extraordinarily unhandy that throughout life he had +considerable difficulty in putting on his gloves, while he had such +trouble with shaving that on his return from India there were found in +his luggage some fifty razors, none of which retained any edge, and +nearly as many strops which had been cut to pieces in his irritated +and ineffectual efforts. If we teach a child manual dexterity it is an +advantage to him, because manual dexterity is seldom associated with +restlessness and irritability of mind. To excel in some handicraft not +only bespeaks the possession of self-control, it helps directly to +cultivate it. The teaching of Froebel and Montessori holds good after +nursery days are over. + + +MENTAL TRAINING + +Mental training enables the child to retain facts in his memory, to +obtain information from as many sources as possible, to understand and +piece them together, and finally to reach fresh conclusions from +previously acquired data. So far as is possible the teacher must +satisfy the natural desire to know the reason of things. It must be +his endeavour to prevent the child from accepting any argument which +he has not fully understood, and which, as a result, he is able not to +reconstruct but only to repeat. Mental work which is slovenly and +perfunctory is as harmful to the child's education as mechanical work +which is bungled and ineffective. Taking advantage of his natural +aptitudes, his interest should be developed and extended in every way +possible. Tasks which are accomplished without enthusiasm are labour +expended in vain, because the knowledge so acquired is not +assimilated and adds nothing to the child's mental growth. There +should be no sharp differentiation between work and play. + + +MORAL TRAINING + +Moral training depends upon the force of example rather than of +precept. Parents must be scrupulously just and truthful to the child, +for his quick perception will detect the slightest deceit, and the +evil impression made on his mind may be lasting. They must confidently +expect conduct from him of a high moral standard, and be careful at +this early age to avoid the common fault of giving a dog a bad name. +If it is said on all sides that a child has an uncontrollable temper, +is an inveterate grumbler, is lacking in all power of concentration, +or has a tendency to deceit, it is likely that the child will act up +to his reputation. He comes in time to regard this failing of his as +part of himself just as much as is the colour of his hair or the +length of his legs. It may be said of a schoolboy that he shows no +aptitude for his work. Term by term the same report is brought home +from school, and each serves only to confirm the boy in his belief +that this failing is part of his nature, and that no effort of his own +can correct it. If one subject only has escaped the condemnation of +his master, then it may be to that study alone that he returns with +zest and enjoyment. Spendthrift sons are manufactured by those fathers +who many times a day proclaim that the boy has no notion of the value +of money. + +And so with children! Parents must take it for granted that they will +display all the virtues they desire in them. They must trust to their +honour always to speak the truth, and always to do their best in work +or play whether they are with them or not. Again and again the +children will fail and their patience will be tried to the utmost. +They must explain how serious is the fault, and for the time being +their trust may have to be removed; but with the promise of amendment +it must again be fully restored and the lapse completely forgotten. If +the child feels he is not trusted he ceases to make any effort, and +lapse will succeed lapse with increasing frequency. + +In efforts at moral training there is often too great an emphasis laid +upon negative virtues. It is wrong to do this: to do that is +forbidden. Children cannot progress by merely avoiding faults any more +than a man may claim to be an agreeable companion at table because he +does not eat peas with a knife or drink with his mouth full. There +must be a constant effort to achieve some positive good, to acquire +knowledge, to do service, to take thought for others, to discipline +self, and the parent will get the best result who is comparatively +blind to failure but quick to encourage effort and to appreciate +success. When the child knows well that he is doing wrong, exhortation +and expostulation are usually of little avail if repeated too often, +and serious talks should only take place at long intervals. + +We know how effective the so-called "therapeutic conversation" may be +in helping some overwrought and nervously exhausted man or woman to +regain peace of mind and self-control. After an intimate conversation +with a medical man who knows how to draw from the patient a free +expression of the doubts, anxieties, and fears which are obsessing +him, many a patient feels as though he had awakened in that instant +from a nightmare, and passes from the consulting-room to find his +troubles become of little account. Not a few patients return to be +reassured once more, and derive new strength on each occasion. Yet +visits such as these must be infrequent or they will lose their power. +Now, just as the physician is well aware that his intervention if too +frequently repeated will lose its effect, so the parent must be chary +of too frequent an appeal to the moral sense of the child. At long +intervals opportunity may be taken with all seriousness to set before +the child ideals of conduct, to-speak to him of the meaning of +character and of self-discipline, and of the standards by which we +judge a man or woman to be weak and despicable, or strong and to be +admired. The effect of such an intimate conversation, never repeated, +may persist throughout life. Constantly reiterated appeals, on the +other hand, do more harm than good. To tell a child daily that he is +"breaking mother's heart," or that he is "disappointing his father," +is to debase the moral appeal and deprive it of its strength. + +For everyday use it is best to cultivate a manner which can indicate +to the child that he is for the moment unpopular, but which at the +same time denies to the small sinner the interest of attempting his +own defence. On the other hand, should the child be reasonably in +doubt as to the nature of his offence we must spare no trouble in +explaining it to him. Punishment will be most effective when the child +is convinced that he is rightly convicted. If it is to act as a real +deterrent, he must agree to be punished--a frame of mind which, if it +can be produced, may be welcomed as a sure sign that training is +proceeding along the right lines. + +By physical training, mental training, and moral training the child's +character is formed and self-discipline is developed. With the child +of neuropathic disposition and inheritance matters may not proceed so +smoothly. Reasoning and conduct may be alike faulty, and the nervous +disturbances may even cause detriment to the physical health. Not that +the nervous child requires an environment different from that of the +normal child. The difficulties which the parents will encounter and +the problems which must be solved differ not in kind but in degree. An +error of environment which is without effect in the normal child may +be sufficient to produce disastrous results in the neuropathic. + +It must be granted that there are some unfortunate children in whom +the moral sense remains absent and cannot be developed--children who +steal and lie, who seem destitute of natural affection, or who appear +to delight in acts of cruelty. These moral degenerates need not be +considered here. Serious errors of conduct, however, in children who +are not degenerate or imbecile, frequently arise directly from faults +of management and can be controlled by correcting these faults. +Suppose, for example, that a child is found to have taken money not +his own. The action of the parents faced with this difficulty and +disappointment will determine to a great extent whether the incident +is productive of permanent damage to the child's character. The +peculiar circumstances of each case must be considered. For example, +the parent must bear in mind the relation in which children stand to +all property. The child possesses nothing of his own; everything +belongs in reality to his father and mother, but of all things +necessary for him he has the free and unquestioned use. Unless his +attention has been specially directed to the conception of ownership +and the nature of theft, he may not have reasoned very closely on the +matter at all. Very probably he knows that it is wrong to take what is +not given him, but he does not regard helping himself to some dainty +from a cupboard as more than an act of disobedience to authority. He +may have imbibed no ideas which place the abstraction of money from a +purse belonging to his parents on a different plane, and which have +taught him to regard such an action as especially dishonourable and +criminal. Finally, a child who, undetected, has more than once taken +money belonging to his father and mother, may pass without much +thought to steal from a visitor or a servant. To deal with such a case +effectively, to ensure that it shall never happen again, requires much +insight. If the father, shocked beyond measure to find his son an +incipient criminal, differing in his guilt in no way from boys who are +sent to reformatories as bad characters, convinces the child that +although he did not realise it, he has shown himself unworthy of any +further trust, untold harm will be done. Almost certainly the child +will act in the future according to the suggestions which are thus +implanted in his mind. If the household eyes him askance as a thief, +if confidence is withdrawn from him, he sees himself as others see him +and will react to the suggestions by repeating the offence. The +seriousness of what he has done should be explained to him, and after +due punishment he must be restored completely and ostentatiously to +absolute trust. Only by showing confidence in him can we hope to do +away with the dangers of the whole incident. To inculcate good habits +and encourage good behaviour we must let the child build up his own +reputation for these virtues. It need not make him priggish or +self-satisfied if parents let him understand that they take pride in +seeing him practise and develop the virtue they aim at. For example, +it is desired above all that he should always speak the truth. Then +they must ostentatiously attach to him the reputation of truthfulness +and show their pride in his possessing it. If he falls from grace they +must remember that he is still a child, and that if that reputation is +lightly taken from him and he is accused of a permanent tendency +towards untruthfulness, he is left hopeless and resigned to evil. Let +any mother make the experiment of presenting to her child in this way +a reputation for some particular virtue. For example, if an older +child shows too great a tendency to tease and interfere with the +younger children, let the mother seize the first opportunity which +presents itself to applaud some action in which he has shown +consideration for the others. Let her comment more than once in the +next few days on how careful and gentle the older child is becoming in +his behaviour to the little ones, and in a little the suggestion will +begin to act until the transformation is complete. If, on the other +hand, the mother adopts the opposite course and rebukes the child for +habitual unkindness, she will be apt to find unkindness persisted in. +The criminal records of the nation show too often the truth of the +saying that "Once a thief always a thief." Deprived of his good +repute, man loses his chief protection against evil and his incentive +to good. + +The inability of a child--and especially of a nervous and sensitive +child--to form conceptions of his own individuality except from ideas +derived from the suggestions of others, gives us the key to our +management of him and to our control of his conduct. He has, as a +rule, a marvellously quick perception of our own estimate of him, and +unconsciously is influenced by it in his conception of his own +personality, and in all his actions. Parents must believe in his +inherent virtue in spite of all lapses. If they despair it cannot be +hid from the child. He knows it intuitively and despairs also. It is +then that they call him incorrigible. If it happens that one parent +becomes estranged from the child, despairs of all improvement, and +sees in all his conduct the natural result of an inborn disposition to +evil, while the other parent holds to the opinion that the child's +nature is good, and to the belief that all will come right, then often +enough the child's conduct shows the effect of these opposite +influences. In contact with the first he steadily deteriorates, +affording proof after proof that judgment against him has been rightly +pronounced. In contact with the other, though his character and +conduct are bound to suffer from such an unhappy experience, he yet +shows the best side of his nature and keeps alive the conviction that +he is not all bad. + +The force of suggestion is still powerful to control conduct and +determine character in later childhood. The impetus given by the +parents in this way is only gradually replaced by the driving power of +his own self-respect--a self-respect based upon self-analysis in the +light of the greater experience he has acquired. + + + + +CHAPTER X + +NERVOUSNESS IN OLDER CHILDREN + + +In older children the line which separates naughtiness, fractiousness, +and restlessness from definite neuropathy begins to be more marked. +The nature of the young child, taking its colour from its +surroundings, is sensitive, mobile, and inconstant. With every year +that passes, the normal child loses something of this impressionable +and fluid quality. With increasing experience and with a growing power +to argue from ascertained facts, character becomes formed, and if +tempered by discipline will come to present a more and more unyielding +surface to environment, until finally it becomes set into the +stability of adult age. + +We may perhaps, with some approach to truth, look upon the adult +neurotic as one whose character retains something of the +impressionable quality of childhood throughout life, so that, to the +last, environment influences conduct more than is natural. + +All the emotions of neurotic persons are exaggerated. Disappointments +over trifles cause serious upsets; grief becomes overmastering. +Violent and perhaps ill-conceived affection for individuals is apt to +be followed by bitter dislike and angry quarrelling. On the physical +side, sense perception is abnormally acute, and many sensations which +do not usually rise up into consciousness at all become a source of +almost intolerable suffering. To these most unhappy people summer is +too hot and winter too cold; fresh air is an uncomfortable draught, +while too close an atmosphere produces symptoms of impending +suffocation. + +In some neurotics there is an excessive interest in all the processes +of the life of the body, and when attention is once attracted to that +which usually proceeds unconsciously, symptoms of discomfort are apt +to arise. Thus so simple an act as swallowing may become difficult, or +for the time being impossible. To breathe properly and without a sense +of suffocation may seem to require the sustained attention of the +patient; or again, the voice may be suddenly lost. + +More commonly, perhaps, neuropathy exhibits itself in an undue +tendency to show signs of fatigue upon exertion of any sort, mental or +physical. Sustained interest in any pursuit or task becomes +impossible. Nameless fears and unaccountable sensations of dread +establish themselves suddenly and without warning, and may be +accompanied on the physical side by palpitation, flushing, headache, +or acute digestive disturbances. + +All these manifestations are best controlled by selecting a suitable +environment, and as a rule the character of the environment is +determined by the temperament and disposition of those who live in +close contact with the patient. Like the tiny children with whom we +have dealt so far, the behaviour of neuropathic persons is subject +wholly to the direction of stronger and more dominant natures. With +faulty management at the hands of those around them, no matter how +loving and patient these may be, the conduct of the neurotic tends to +become abnormal. + +In children beyond earliest infancy we recognise a gradual approach to +the conditions of adult life. Fractiousness and naughtiness, +ungovernable fits of temper, inconsolable weeping and inexplicable +fears should disappear with early childhood even if management has not +been perfect. If they persist to older childhood we shall find in an +increasing percentage of cases evidence of definite neuropathic +tendencies which urgently call for investigation and for a precise +appreciation of the nature of the abnormality. It may be that the only +effective treatment is that which we recognise as essential in the +grosser mental disturbances--removal from the surroundings in which +the abnormal conduct has had free play, and separation from the +relatives whose anxiety and alarm cannot be hidden. + +In young nervous children fear is the most prominent psychical +symptom. The children are afraid of everything strange with which they +come in contact. They are afraid of animals, of a strange face, or an +unfamiliar room. Older children usually manage to control themselves, +suppress their tears, and prevent themselves from crying out, but it +is nevertheless easy to detect the struggle. + +Often we find those distressing attacks to which the name +"night-terrors" has been given. The child wakes with a cry,--usually +soon after he has gone to sleep,--sits up in bed and shows signs of +extreme terror, gazing at some object of his dreams with wide-open +startled eyes, begging his nurse or mother to keep off the black dog, +or the man, or whatever the vision may be. Even after the light is +turned up and the child has been comforted, the terror continues, and +half an hour may elapse before he becomes quiet and can be persuaded +to go back to bed. In the morning as a rule he remembers nothing at +all. + +Phobias of all sorts are common in nervous children, and result from a +morbid exaggeration of the instinct for self-preservation. Some cannot +bear to look from a height, others grow confused and frightened in a +crowd; dread of travelling, of being in an enclosed space such as a +church or a schoolroom, or of handling sharp objects may develop into +a constant obsession. I have known a little girl who was seized with +violent fear whenever her father or mother was absent from the house, +and she would stand for hours at the window in an agony of terror lest +some harm should have befallen them. As if with some strange notion of +propitiating the powers of darkness these children will often +constantly perform some action and will refuse to be happy until they +have done so. The same little girl who suffered such torments of +anxiety in her parents' absence would always refuse to go to bed +unless she had stood in turn on all the doormats on the staircase of +her home. Other children feel themselves forced to utter certain words +or to go through certain rhythmical movements. They fully understand +that the fear in their mind is irrational and devoid of foundation, +but they are unable to expel it. Often it is hugged as a jealous +secret, so that the childish suffering is only revealed to others +years afterwards, when adult age has brought freedom from it. We will +do well to try by skilful questioning to gain an insight into the +mental processes of a child when we find him showing an uncontrollable +desire to touch lamp-posts or to stand in certain positions; or when +he develops an excessive fear of getting dirty, or is constantly +washing his hands to purify them from some fancied contamination. + +The treatment of all these symptoms calls for much insight. The +child's confidence must be completely secured, and he must be +encouraged to tell of all his sensations and of the reasons which +prompt his actions. The nervous child has a horror of appearing unlike +other children, and will suffer in silence. If his troubles are +brought into the light of day with kindness and sympathy they will +melt before his eyes. Even night-terrors are, as a rule, determined by +the suppressed fears of his waking hours. If they are provoked by his +experiences at school, by the fear of punishment or by dismay at a +task that has proved beyond his powers, he should be taken away from +school for the time being. Night-terrors are said to be aggravated by +nasal obstruction due to adenoid vegetations. Clothing at night should +be light and porous, and particular attention should be paid to the +need for free ventilation. + +We have spoken in an earlier chapter of the trouble sometimes +experienced in inducing a nervous child to go to sleep. In older +children insomnia is common enough. Even when sleep comes it may be +light and broken, as though the child slept just below the surface of +consciousness and did not descend into the depths of sound and +tranquil slumber. We have often noticed how different is the estimate +of the patient from that of the nurse as to the number of hours of +sleep during the night. The sick man maintains that he has hardly +slept at all, whilst the nurse, drawing us aside, whispers in our ear +that he has slept most of the night. In estimating sleep we have to +consider not only its duration, but also its depth, and the patient +who denies that he has slept at all has lain perhaps half the night +with an active restless brain betwixt sleep and wakefulness. Often +enough when he comes to consider in the morning the problems that +vexed his soul at midnight, he is quite unable to recall their nature, +and recognises them as the airy stuff that dreams are made of. +Although in a sense asleep he may have retained a half-consciousness +of his surroundings and a sense of despair at the continued absence of +a sounder sleep. + +With nervous children we are apt to find sleep which is of little +depth and which constantly shows evidence of a too-active brain. The +body is tossed to and fro, words are muttered, and the respiration is +hurried and with a change in rhythm, because there is no depth of +anaesthesia. The body still responds to the impulses of the too-active +brain. From the nature of his dream--as shown by chance words +overheard--we may sometimes gather hints to help us to find where the +elements of unrest in his daily life lie. Sleep-walking is only a +further stage in this same disorder of sleep, in which the dream has +become so vivid that it is translated into motor action. + +If a child begins to suffer from active sleeplessness we must not make +the mistake of urging him to sleep. He is no more capable than we are +ourselves of achieving sleep by an effort of will power. To urge him +to sleep is likely to cause him to keep awake because we direct his +attention to the difficulty and make him fear that sleep will not +come. If he understands that all that he needs is rest, he will +probably fall asleep without further trouble. + +Day-dreams also may become abnormal, and tell of an unduly nervous +temperament. Any one who watches a little child at play will realise +the strength of his power of imagination. The story of Red Riding Hood +told by the nursery fire excites in the mind of the child an +unquestioning belief which is never granted in later life to the most +elaborate efforts of the theatre. All this imaginative force is +natural for the child. It becomes abnormal only when things seen and +acts performed in imagination are so vivid as to produce the +impression of actual occurrences, and when the child is so under the +sway of his day-dreams that he fails to realise the difference between +pretence and reality. Imagination which keeps in touch with reality by +means of books and dolls and toys is natural enough. Not so +imagination which leads to communion with unseen familiars or to acts +of violence due to the organisation of "conspiracies" or "robber +bands" amongst schoolboys. + +If evidence of abnormal imagination appears, the child must be kept in +close touch with reality. We must give him interesting and rational +occupation, such as drawing, painting, the making of collections of +all sorts, gardening, manual work, and so forth. In older children we +must especially supervise the reading. + +In many nervous children we find a faulty contact with environment, so +that instead of becoming interested in the thousand-and-one happenings +of everyday life and experiences, they become introspective and +self-conscious. As a result, sensations of all sorts, which are +commonly insufficient to arouse the conscious mind, attract attention +and, rising into consciousness, occupy the interest to the exclusion +of everything else. The conscious mind is not capable of being +occupied by more than one thing at a time. If attention is +concentrated upon external matters, bodily sensations, even extreme +pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells +us, hardly feels the scalping-knife as he shouts his death song. The +soldier in the excitement of battle is often bereft of all sense of +pain. On the other hand, the patient who is morbidly self-conscious +becomes oblivious of his surroundings while he suffers intensely from +sensations which are usually not appreciated at all. Self-conscious +children will complain much of breathlessness and a sense of +suffocation, of headache, of palpitation, of intolerable itching, of +the pressure of clothing, or of flushing and a sense of heat. +Excessive introspection influences their conduct in many ways. At +children's parties, for example, they will be found wandering about +unhappy, dazed and unable to feel the reality of the surroundings +which afford such joy to the others; or they may be anxious to join in +play, but finding themselves called upon to take their turn are apt to +stand helplessly inactive, or to burst into tears. At school, though +they may be really quick to learn, they will often be found oblivious +of all that has gone on around them, not from stupidity, but from +inability to dissociate their thoughts from themselves and to +concentrate attention upon the matter in hand. In such a case we must +aim at developing the child's interest to the exclusion of this morbid +introspection. Taking advantage of his individual aptitude, we must +strengthen his hold upon externals in every way possible, and we must +explain to him the nature of his failing and teach him that his +salvation lies in cultivating his capacity for paying attention to +things around him and developing an interest in suitable occupations. + +Fainting fits are not uncommon amongst nervous children from about +the sixth year onwards, and are apt to give rise to an unwarranted +suspicion of epilepsy. In other cases fears have been aroused that the +heart may be diseased. In children who faint habitually the nervous +control of the circulation is deficient. We notice that when they are +tired by play, or when they are suffering from the reaction that +follows excitement of any sort, the face is apt to become pale, and +dark lines may appear under the eyes. Yet there may be no true anaemia +present: it is only that the skin is poorly supplied with blood for +the moment. After a little rest in bed, or under the influence of a +new excitement, the colour returns, and the tired look vanishes. If +children of this type are made to stand motionless for any length of +time, and if at the same time there is nothing to attract their +interest or attention--a combination of circumstances which unhappily +is sometimes to be found during early morning prayers at school--the +want of tone in the blood vessels may leave the brain so anaemic that +fainting follows. The first fainting attack is a considerable +misfortune, because the fear of a recurrence is a potent cause of a +repetition. Standing upright with the body at rest and the mind +vacant, the circulation stagnates, the boy's mind is attracted by the +suggestion, he fears that he will faint as he has done before, and he +faints. Schoolmasters are well aware that if one or two boys faint in +chapel and are carried out, the trouble may grow to the proportion of +a veritable epidemic. It is important that this habit of fainting +should be combated not only by general means to improve the tone of +the body and circulation, but also by taking care that the child +understands the nature of the fainting fit, and the part which +association of ideas plays in producing it. Disease of the heart +seldom gives rise to fainting. + +The same vasomotor instability which shows itself in the tendency to +syncopal attacks is apparent in many other ways. Sudden sensations of +heat and of flushing, equally sudden attacks of pallor, coldness of +the extremities, abundant perspiration,--raising in the mind of the +anxious mother the fear of consumption,--and excessive diuresis are +common accompaniments. A further group of symptoms is provided by the +extreme sensibility of the digestive apparatus. Dyspepsia, +hyperaesthesia of the intestinal tract, viscero-motor atonies and +spasms, and anomalies of the secretions, whether specific like that of +the gastric juice or indifferent like that of the nasal, pharyngeal, +gastric, and intestinal mucus, are all of common occurrence. Whenever +the nervous child is subjected to any exhausting experience, any +excitement, pleasurable or the reverse, or any undue exertion, whether +mental or physical, one may note the subsequent gastro-intestinal +derangement, including even a coating of the tongue. The slightest +deviation from the usual diet, the most trivial fatigue, a chill of +the body, even a change in the temperature of the food may set loose +the most extreme reactions in the gastro-intestinal tract--motor, +sensory, or secretory. It is not an accident that so often the mucous +diarrhoea, which may have afflicted an excitable child in London for +many months, and which a visit to the seaside, with all its healthy +activities, may seem to have completely cured, relapses within a day +or two of the return to the restricted environment and uninteresting +routine of life in London. The child who was happy and busy and at +peace with himself, at play in the open air, resents the sudden +cessation of all this, and the nervous unrest returns. To attempt +treatment by dietetic restrictions alone is to deal only with a +symptom. The gastro-intestinal reactions are so violent that the +parents are generally voluble on the subject of the many foods which +cannot be taken and the few which are not suspect. To prescribe rigid +tables of diet is to add to the alarm of the mother, and to sustain +her in the belief that the child is in daily danger of being poisoned +by a variety of common articles of diet. Only by lowering the +excitability of the nervous system, by occupying the mind and giving +strength to the child's powers of control can we effectively combat +the hyperaesthesia. If necessary the personnel of the management of +the child will have to be altered. There may be no other way to +achieve certain and rapid improvement in a condition which is causing +grave danger to the child and very genuine distress and suffering to +the parents. A violent reaction to intoxications of all sorts is a +further stigma of nervous instability. Sudden and even inexplicable +rises of temperature are frequent complaints, and the constitutional +effects of even trivial local infections are apt to be +disproportionately great. + +Fatigue is easily induced and is exhibited in all varieties of +activity--mental, physical, or visceral. Mental work may produce +fatigue with extreme readiness even although the quality of the work +may remain of a high standard. To Darwin and to Zola work for more +than three hours daily was an impossibility, and yet their work done +under these restrictions excites all men's admiration. The palpitation +and breathlessness which follows upon trivial exertion, such as +climbing a flight of stairs, is a good example of visceral fatigue. + +Among adult neuropaths we recognise the harm which may be done by +unwise speeches on the part of relatives, or still more on the part of +doctors. A chance word from a doctor or nurse off their guard for the +moment will implant in the minds of many such a person the unyielding +conviction that he or she is suffering from some gastric complaint, +from some cardiac affection, or from some constriction of the bowel. +It may take the united force of many doctors to uproot this +pathological doubt which was implanted so easily and so carelessly. +The medical student is notoriously prone to recognise in himself the +symptoms of ailments which he hears discussed. Little children, too, +are apt to suffer in the same way. How much illness could be avoided +if mothers would cease to erect some single manifestation of +insufficient nervous control into a local disorder which becomes an +object of anxiety to the child and to the whole household. + +Undue liability to fatigue, irritability, instability, lack of +control over the emotions, extreme suggestibility, prompt and +exaggerated reactions to toxins of all sorts, excessive vasomotor +reactions and anomalies of secretion, weakness of the +gastro-intestinal apparatus--these, and many other symptoms, are of +everyday occurrence in the nervous child. To discuss them more fully +would be to pass too far from our nursery studies into a consideration +of psychological medicine. + + + + +CHAPTER XI + +NERVOUSNESS AND PHYSIQUE + + +It has already been said that symptoms of nervousness are often +accompanied by faults in the physical development of the child. The +defects may assume so many forms as to make any attempt at description +very difficult. Nevertheless, certain types of physical defect present +themselves with sufficient frequency, in combination with neurosis, to +merit a detailed description. For example, we recognise a type of +nervous child which is marked by a persistence into later childhood of +certain infantile characteristics of the build and shape of body. +Further, we meet with a group characterised by a special want of tone +in the skeletal muscles, by lordosis, by postural albuminuria, and by +abdominal and intestinal disturbances of various sorts. We recognise +also the rheumatic type of child with a tendency to chorea, and in +contrast to this a type with listlessness, immobility, and katatonia. +Lastly, in a few children, in boys as well as in girls, we may meet +with cases of hysteria.[3] + +[Footnote 3: If we accept as hysterical all symptoms which are +produced by suggestion and which can be removed by suggestion, we may +correctly speak of a physiological hysteria of childhood, which +includes a very large number of the symptoms discussed. The term is +used here in its older more limited sense.] + +(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS + +During the first year or eighteen months of life, the rounded +infantile shape of body persists. The limbs are short and thick, the +cheeks full and rounded, the thorax and pelvis are small, the abdomen +relatively large and full. The great adipose deposit in the +subcutaneous tissue serves as a depot in which water is stored in +large amounts. In the healthy child of normal development by the end +of the second year a great change has taken place. The shape of the +body has become more like that of an adult in miniature. The limbs +have grown longer and slimmer. The thorax and pelvis have developed so +as to produce relatively a diminution in the size of the abdomen. The +body fat is still considerable, but no longer completely obliterates +the bony prominences of the skeleton. Delay in this change, in this +putting aside of the infantile habit of body, is commonly associated +with a corresponding backwardness in the mental development. Such +children walk late, talk late, learn late to feed themselves, to bite, +and to chew effectively. Watery and fat, they carry with them into +later childhood the infantile susceptibility to catarrhal infections +of the lung, bowel, skin, etc., and they are apt to suffer, in +consequence, from a succession of pyrexial attacks. Nasal catarrh, +bronchitis, otitis media, enteritis, eczema, urticaria papulata, are +apt to follow each other in turn, giving rise in many cases to a +persistent enlargement of the corresponding lymphatic glands. The +effect upon the different tissues of the body of these repeated +infections is very various. We are probably not wrong in attributing +the failure to develop and the persistently infantile appearance to a +prejudicial effect upon the various ductless glands in the body. The +condition is associated with an excessive retention of fluid in the +body, secondary in all probability to alterations in the concentration +and distribution of the saline constituents of the body. A rapid +excretion of salts may be followed by a correspondingly speedy +dehydration of the body, a retention of salts by a sudden increase of +weight. The parathyroid glands are probably closely concerned in +regulating the retention and excretion of salts, and especially of +calcium, a circumstance which becomes of significance when we remember +how frequently rickety changes, tetany, and other convulsive seizures +form part of the clinical picture which we are now considering. While +it is difficult to determine the effect of repeated infections upon +the functions of the endocrine glands, we have clear evidence of the +deleterious influence upon almost all the tissues of the body, the +functioning of which it is more easy to estimate. For example, the +cells of the skin and of the mucous membranes which happen to be +visible to the eye show clear evidence of diminished vitality and +increased vulnerability. Physiological stimuli, incapable of producing +any visible reaction in healthy children, habitually determine widely +spread and persistent inflammatory reactions. For example, the +licking movements of the tongue at the corners of the mouth produce +the little unhealthy fissures which the French call _perleche_. The +physiological stimulus of the erupting tooth is capable of causing a +painful irritation of the gum, so that the child is said to suffer +from teething, accompanied, it may be, and the association is +significant, by "teething convulsions." The irritation of the urine +produces rawness and excoriation of the skin of the prepuce, contact +with intestinal contents not in themselves very abnormal, an +intractable dermatitis of the buttocks or a persistent diarrhoea and +enteral catarrh. Improvement in the general health, the result of the +cessation for the time being of the recurrent infections, perhaps +consequent upon improved hygienic conditions, always determines the +rapid disappearance of all these accompaniments of the general +diminution of tissue vitality. + +The muscular system and the bones are commonly also involved, so that +rickety changes are often found in these infantile and watery +children. In early childhood the processes of calcification and +decalcification proceed side by side and with great rapidity, and in +health there is always a balance on the side of the constructive +process. In the children whom we are now considering, saturated as +they are, from time to time, with the toxins resulting from repeated +infection, ossification may be so interfered with as to cause +softening and bending, with the evolution of a state of rickets. +Between bone and muscle, too, we find a close relationship. We do not +find powerful muscles with softened bone, nor flabby muscle with +rigid and well-formed bone. + +In the nervous system, the conditions are somewhat different. In skin, +in bone, and in muscle new cell elements are constantly being formed, +and the life of the individual cell is relatively short. In the +nervous system, on the other hand, the individual cells are long +lived. Their life-history may even be coterminous with that of the +individual, and if destroyed they are not replaced. Nevertheless, they +do not escape undamaged in the general disturbance. In a deprivation +of calcium we have, in all probability, the explanation of the +increased irritability of peripheral nerves and of the tendency to +convulsive seizures of all sorts which is a common accompaniment of +the condition. Convulsions, laryngismus stridulus, tetany, or +carpopedal spasm are all frequently met with. In crying, the children +hold their breath to the point of producing extreme cyanosis, ending, +as the spasm relaxes, with a crowing inspiration, which resembles and +yet differs in tone from both the whoop of whooping-cough and the +crowing inspiration of croup. + +Apart, however, from this tendency to convulsive seizures the nervous +system of these children is abnormal. As a rule they are excitable, +and develop late the power to control their emotions. Lagging behind +in physical development and in the capacity to interest themselves in +the pursuits of normal children, their emotional state remains that of +a much younger child. In the infant classes at schools they are +recognised as dullards, learning slowly, speaking badly, and lacking +co-ordination in all muscular movements. + +The clinical picture so depicted is encountered with extreme frequency +among the children of the poor in our large cities. To find a name for +the condition is no easy matter. To call it "rickets" is to place an +undue emphasis upon the bony changes which, though common, are by no +means invariable. Elsewhere I have suggested the name status +catarrhalis, on an analogy with the name status lymphaticus, which in +the post-mortem room is used to describe the secondary overgrowth of +lymphatic tissue which is found in these catarrhal children. In the +present connection it is of interest to us to note how commonly the +nervous system is involved in the general picture and the frequency +both of convulsive disorders and of neuropathy. + +The nervous symptoms of both sorts are to be allayed only by improving +the general hygiene of the child and raising its resistance against +infection. A sufficiency of fresh air and of sunlight, and a +management which encourages independence of action in the child, are +both necessary. The diet is of the first importance. It should be +sufficient, and no more than sufficient, to cover the physiological +needs of the child for food. The majority of these children have +enormous appetites, and excess of food, and especially of carbohydrate +food, plays some part in the production of the disturbance. We must +guard against overfeeding, against want of air and want of exercise, +and against those errors of management described in previous chapters, +which produce the maximum of disturbance in this type of child. + + +(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA + +At an older age, in children from the fifth year onwards, a second +type of physical defect associated with pronounced nervous disturbance +presents itself with some frequency. The body is thin and badly +nourished, and the muscular system especially poorly developed and +very lax in tone. The most striking feature is the extreme lordosis, +accompanied usually by a secondary and compensatory curve in the +cervico-dorsal region, so that the shoulders are rounded, with the +head poked forward. Viewed from in front the abdomen is seen to be +prominent, overhanging the symphysis pubis, while the shoulders have +receded far backwards. The scapulae have been dragged apart, as though +by the weight of the dependent arms, with eversion of their vertebral +borders and lowering of the points of the shoulders. The position +which they adopt is that into which the body falls when it ceases to +be braced by strong muscular support. The muscular system is here so +weakly developed and so toneless that the posture is determined by the +bony structure and its ligamentous attachments. + +The lordosis resembles the similar deformity which develops in cases +of primary myopathy, when the spinal muscles have undergone complete +atrophy. As in myopathy the movements are very uncertain. The +children are apt to fall heavily when the centre of gravity is +suddenly displaced, because their upright posture is maintained by +balancing the trunk upon the support of the pelvis. The frequency and +severity of the falls which these children suffer is a common +complaint of the mother. The faulty posture is often associated with +slight albuminuria. Its appearance is very capricious, but it is +dependent to a great extent upon the assumption of the erect posture. +There has been much discussion as to its explanation. It has been +argued that the lordosis itself produces the albuminuria by mechanical +compression of the renal vein, and it is said that albuminuria can be +produced, even in the prone position, by placing the child in a +plaster jacket applied so as to maintain the position of lordosis. +Other observers, however, have not obtained this result. It seems most +likely that the albuminuria is due to defective tone in the vasomotor +musculature, comparable in every way to the defective tone in the +muscles of the skeleton. We have often further evidence of vasomotor +weakness. Fainting attacks are so common as to be the rule rather than +the exception. Again, mothers are likely to complain of the child's +pallor and of dark lines under the eyes, especially after exertion or +in the reaction which follows excitement of any sort. As a rule a +blood count will not show any very striking evidence of true anaemia. +The pallor is of vasomotor origin, determined by faults in the +distribution of the blood from vasomotor weakness and not by deficient +blood formation. Circulatory and vasomotor disturbance probably also +accounts for the dyspeptic pains and vomiting which commonly accompany +any emotional excitement, or follow any unusual exertion or fatiguing +experience. Constipation is a common, and mucous diarrhoea an +occasional, symptom. The abdomen is often pigmented. The hands and +feet are usually cold and cyanosed. + +The extreme nervousness of the children is the point upon which most +stress may be laid in the present connection. The association of +albuminuria with neurosis in childhood has been noticed by many +observers. The gastric and intestinal symptoms are especially +characteristic. If the condition of the children is not materially +improved, and if the symptoms, both of the physical defect and of the +nervous disturbance, are not cut short, we may predict that in adult +age their lives will be made miserable by a variety of abdominal +symptoms dependent both on the vasomotor disturbance and upon the +accompanying neurosis. Now that surgery forms so large a part of our +therapeutic proceedings, they may not reach middle life without being +submitted to one or more surgical operations. With good management +both on the physical side and on the moral or psychological side they +can be made into strong and useful members of society. + +The treatment of these cases may be summed up as follows: + +_(a)_ We must search for any source of infection, a source which is +often to be found in the condition of the tonsils. Enucleation may +then be indicated as the first step in treatment. + +_(b)_ Massage and gymnastic exercises calculated to improve the +muscular tone, while every effort is made to secure for the child as +perfect hygiene in the environment as possible. + +_(c)_ The stimulating effect of cold douches is often very evident in +improving the vasomotor tone. These children, however, will not stand +well the abstraction of heat from their thin and chilly little bodies, +so that it is a good plan before the colder douche to immerse the +child in a hot bath and to return again to the bath momentarily +afterwards. With these precautions children will often enjoy a cold +spray, the temperature of which may be constantly lowered as they +become used to it. Prolonged hot bathing has a correspondingly +prejudicial effect. + +_(d)_ We must be on the watch to prevent the development of further +postural deformities, such as scoliosis. If a child of strong muscular +tone and good physique habitually adopts some posture, curled up, it +may be, in some favourite easy-chair, there is little likelihood that +its constant assumption will produce deformity. When the muscular +system is lax and weak, on the other hand, deformity such as scoliosis +is very readily caused. It is important, for example, to see that the +child does not habitually incline to one side in reading or writing. +When there is little energy for free and energetic play the children +are apt to become great bookworms. If there is shortsightedness, the +dangers are correspondingly increased. A special chair may be made +with a well-fitting back and the seat a little tilted upwards so as to +throw the child's trunk on to the support of the back. Lastly, a desk, +the height of which can be regulated at will, can be swung into the +proper position. The child, sitting straight and square, with the +weight supported by the foot-rest and back as well as by the seat of +the chair, should be taught to write with an upright hand, avoiding +the slope which leads to sitting sideways with the left shoulder +lowered. + +(e) Malt extract, cod liver oil, Parrish's food, and other tonics may +be of undoubted service. + + +(3) RHEUMATISM AND CHOREA + +It is certain that there is a close association between rheumatism in +childhood and the common nervous affection known as chorea. We are +still ignorant of the precise nature of the infection which we know as +rheumatism. There is much to suggest that in rheumatism we have to +deal only with a further stage in those catarrhal infections to which +so much infantile ill-health is to be attributed, and that +endocarditis and arthritis, when they arise, signalise the entry of +these catarrhal, non-pyogenic organisms into the blood stream, +overcoming at last the barrier of lymphoid tissue which has +hypertrophied to oppose their passage. Certainly the connection of +rheumatism with catarrhal infections of the mucous membranes and +adenoid enlargements of all sorts is a close one. Whatever its +nature, the rheumatic infection in childhood is more lasting and +chronic than in adult life. Rheumatism in childhood is not manifested +by acute and short-lived attacks of great severity so much as by a +long-continued succession of symptoms of a subacute nature, a +transient arthritis, perhaps, succeeding an attack of sore throat with +torticollis, to be followed by carditis, to be followed again by +another attack of tonsillitis. And so the cycle of symptoms revolves. +In most cases the child grows thin and weak; in most cases he becomes +restless, irritable, and unhappy; often there is definite chorea. Of +this cerebral irritability chorea is the expression. In adults, chorea +is perhaps more obviously associated with mental stress of all sorts +and with states of excitement and agitation. In the case of little +children it is often only the mother who really appreciates how +radical an alteration the child's whole nature has undergone, and how +great the element of nervous overstrain has been before the chorea has +appeared. + +Of the treatment of chorea there is no need to speak. It is purely +symptomatic. Isolation, best perhaps away from home, as might be +expected, gives the best results. If there are pronounced rheumatic +symptoms, the salicylates will be needed; if there is anaemia, arsenic +and iron; if there is sleeplessness and great restlessness, bromides +or chloral. Hypnotism is often almost instantly successful, but, apart +from hypnosis, curative suggestions proceeding from the attendants +form the principal means at our disposal. + + +(4) EXHAUSTION AND KATATONIA + +A large number of children, in convalescence from infective disorders, +when the nutrition of the body has fallen to a low ebb, show as +evidence of cerebral exhaustion a group of symptoms which in a sense +are the reverse of those which characterise cerebral irritation and +chorea. The healthy child is a creature of free movement. The children +we are now considering will sit for a long time motionless. The +expression of their faces is fixed, immobile, and melancholy. If the +arm or leg is raised it will be held thus outstretched without any +attempt to restore it to a more natural position of rest for minutes +at a time. The posture and expression remind us at once of the +katatonia which is symptomatic of dementia praecox and other stuporose +and melancholiac conditions in adult life. Symptoms of this sort are +especially common in children with intestinal and alimentary +disturbances of great chronicity. + +The symptom is so frequently met with that it is strange that it +should have attracted so little attention as compared with the +contrasting condition of chorea. And yet it is of more serious +significance, more difficult to overcome, and with a greater danger +that permanent symptoms of neurasthenia will result. In early +childhood a careful dietetic regime, suitable hygienic surroundings, +and a stimulating psychical atmosphere will often effect great +improvement. As in chorea, however, relapses are frequent, and there +are cases which for some unexplained reason are peculiarly resistant +to all remedial influences. + + +(5) HYSTERIA + +In hysteria, in contrast to the types previously described, the +infective element may be completely absent. Except in some special +features of minor importance the symptoms of hysteria do not differ +from those of adults, and, as in adult age, the condition of hysteria +may be present although the physical development may be perfect. We +cannot here speak of any physical characteristics which are associated +with the nervous symptoms. + +The third or fourth year represents the age limit, below which +hysterical symptoms do not appear. Thereafter they may be occasionally +met with, with increasing frequency. At first, in the earlier years of +childhood, there is no preponderance in the female sex. As puberty +approaches, girls suffer more than boys. + +It may be said to be characteristic of hysteria in childhood that its +symptoms are less complex and varied than in adult life. The naive +imagination of the child is content with some single symptom, and is +less apt to meet the physician half-way when he looks for the +so-called stigmata. Similarly mono-symptomatic hysteria is +characteristic of oases occurring in the uneducated or peasant class. +In children, hysterical pain, hysterical contractures or palsies, +mutism, and aphonia are the most usual symptoms. Hysterical deafness, +blindness, and dysphagia are manifestations of great rarity in +childhood. + + + + +CHAPTER XII + +THE NERVOUS CHILD IN SICKNESS + + +In time of sickness the management of the nervous child becomes very +difficult. Restlessness and opposition may reach such a pitch that it +may be almost impossible to confine the patient to bed or to carry out +the simplest treatment. Sometimes days may elapse before the +sick-nurse who is installed to take the place of the child's usual +attendant is able to approach the cot or do any service to the child +without provoking a paroxysm of screaming. In such a case any +systematic examination is often out of the question, with the result +that the diagnosis may be delayed or rendered impossible. There is +only one reassuring feature of a situation, which arises only in +nurseries in which the management of the children is at fault; the +doctor has learned from experience that this pronounced opposition of +the child to himself, to the nurse, and even to the mother, is of +itself a reassuring sign, indicating, as a rule, that the condition is +not one of grave danger or extreme severity. When the child is more +seriously ill, opposition almost always disappears, and the child lies +before us limp and passive. Only with approaching recovery or +convalescence does his spirit return and renewed opposition show +itself. + +Extreme nervousness in childhood carries with it a certain liability +towards what is known as "delicacy of constitution." The sensitiveness +of the children is so great that they react with striking symptoms to +disturbances so trivial that they would hardly incommode the child of +more stable nervous constitution. For example, a simple cold in the +head, or a sore throat, may cause a convulsion or a condition of +nervous irritability which may even arouse the suspicion that +meningitis is present. Or, again, a little pharyngeal irritation which +would ordinarily be incapable of disturbing sleep may be sufficient to +keep the child wide awake all night with persistent and violent +coughing. The little irritating papules of nettlerash from which many +children suffer are commonly disregarded by busy, happy children +during the day, and even at night hardly suffice to cause disturbance. +The nervous child, on the other hand, will scratch them again and +again till they bleed, tearing at them with his nails, and making deep +and painful sores. + +The temperature is commonly unstable and readily elevated. Moreover, +feverishness from whatever cause is often accompanied by an active +delirium, which is apt to occasion unnecessary alarm. This symptom of +delirium is always a manifestation of an excitable temperament. I +remember being called to see a young woman who was thought to be +suffering from acute mania. Examination showed that she was suffering +from pneumonia in the early stages. It was only later that we +discovered that she had always been of an unstable nervous +temperament, and had been in an asylum some years before. Those of us +who are fortunate in possessing a placid temperament and have +developed a high degree of self-control are not likely to show +delirium as a prominent symptom should we fall ill with fever; just as +we should not struggle and scream too violently when we "come round" +from having gas at the dentist's. Looked at from this point of view, +it is natural for all children to become delirious readily, and this +tendency is peculiarly marked in those who are unduly nervous. + +As a consequence of this extreme sensitiveness, the nervous child is +likely to suffer more than others from a succession of comparatively +trifling ailments and disturbances. The delicacy of the child has, in +this sense, a real existence, and is not confined to the imagination +of over-anxious and apprehensive parents. No doubt the nervous mother +of an only child does worry unnecessarily, and is far too prone to +feed her fears by the daily use of the thermometer or the +weighing-machine; but her friends who are happy in the possession of +numerous and placid children are not justified in laying the whole +blame upon her too great solicitude. Children who are members of large +families, whose nervous systems have been strengthened by contact with +their brothers and sisters, are not habitually upset by trifles, and +suffer even serious illnesses with symptoms of less severity. Nervous +children, and only children, on the other hand, show the opposite +extreme. Nevertheless, the mother of a nervous and delicate child--a +child, that is to say, who, even if he is not permanently an invalid, +nevertheless never seems quite well and lacks the robustness of other +children--should realise clearly how much of this sensitiveness is due +to the atmosphere of unrest and too great solicitude which surrounds +him. It is a matter of universal experience that excess of care for +only children has a depressing influence which affects their +character, their physical constitution, and their entire vitality. At +all costs we must hide our own anxieties from the child, and we must +treat his illnesses in as matter-of-fact a way as possible. + +When illness comes, his daily routine should be interrupted as little +as possible. In dealing with nervous children, it is often better to +lay aside treatment altogether rather than to carry out a variety of +therapeutic procedures which have the effect of concentrating the +child's mind upon his symptoms. When we grown-up people are sick, we +often find a great deal of comfort in submitting ourselves to some +form of treatment. We have great faith, we say, in this remedy or in +that. It is _our_ remedy, a _nostrum_. The physician knows well that +the opportunities which are presented to him of intervening +effectually to cut short the processes of disease by the use of +specific cures are not very numerous, and that often enough the +justification for his prescription is the soothing effect which it +may exercise upon the mind of the patient, who, believing either in +the physician or in his remedy, finds confidence and patience till +recovery ensues. As a rule this form of consolation is denied to +little children. They have no belief in the efficacy of the remedies +which are applied with such vigour and persistence. Indeed, it is not +the child, but his anxious mother, who finds comfort in the thought +that everything possible has been done. Therefore, a prescription must +be written and changed almost daily, the child's chest must be +anointed with oil, and the air of the sick-room made heavy with some +aromatic substance for inhalation, and all this when the disturbance +is of itself unimportant, and owes its severity only to the undue +sensitiveness of the child's nervous system. + +The very name of illness should be banished from such nurseries. +Everything should be done to reassure the child and to make light of +his symptoms, and we can keep the most scrupulous watch over his +health without allowing him to perceive at all that our eye is on him. +With older children the evil results of suggestions, unconsciously +conveyed to them by the apprehension of their parents, become very +obvious. The visit of the doctor, to whom in the child's hearing all +the symptoms are related, is often followed by an aggravation which is +apt to be attributed to his well-meant prescription. The harm done by +examinations, which are specially calculated to appeal to the child's +imagination, as, for instance, an X-ray examination, is often clearly +apparent. I remember a schoolboy of thirteen who was sent to me +because he had constantly complained of severe abdominal pain. He was +a nervous child with a habit spasm, the son of a highly neurotic +father and an overanxious mother. An X-ray examination was made, but +showed nothing amiss. The child's interest and preoccupation in the +examination was painfully obvious. That night his restraint broke down +altogether, and he screamed with pain, declaring that it had become +insupportable. Younger children, less imaginative but equally +perverse, noticing how anxiously their mothers view their symptoms, +will often make complaint merely to attract attention and to excite +expressions of pity or condolence. Sometimes they will enforce their +will by an appeal to their symptoms. I have had a little patient of no +more than thirteen months of age who suffered severely and for a long +time from eczema, and who in this way used his affliction to ensure +that he got his own way. If he was not given what he wanted +immediately he would fall to scratching, with an expression upon his +face which could not be mistaken. To him, poor child, the grown-up +people around seemed possessed of but one desire--to stop his +scratching; and he had learnt that if he showed himself determined to +scratch they would give way on every other point. + +The ill-effects of departing too readily from ordinary nursery routine +on account of a little illness, and of adopting straightway a variety +of measures of treatment, is well shown in cases of asthma in +children. The asthmatic child is almost always of a highly nervous +temperament, and often passionate and ungovernable. Often the most +effective treatment of an attack, which usually comes on some hours +after going to bed, is to make little of it, to talk naturally and +calmly to the child, to turn on the light, and to allow him, if he +will, to busy himself with toys or books. To be seized with panic, to +send post-haste for the doctor, to carry the patient to the open +window, to burn strong-smelling vapours, and so forth, not only is apt +to prolong the nervous spasm on this occasion, but makes it likely +that a strong impression will be left in his mind which by +auto-suggestion will provoke another attack shortly. With nervous +children a seeming neglect is the best treatment of all trivial +disorders. Meanwhile we can redouble our efforts to remedy defects in +management, and to obtain an environment which will gradually lower +the heightened nervous irritability. + +When the illness is of a more serious nature, as has been said, the +restlessness as a rule promptly disappears. In each case it must be +decided whether it is best for the child to be nursed by his mother +and his own nurse, or by a sick-nurse. In the latter event the +ordinary nurse and the mother should absent themselves from the +sick-room as much as possible. Often the firm routine of the hospital +nurse is all that is wanted to obtain rest. Less often, the child will +be quiet with his own nurse, and quite unmanageable with a stranger. + +There is, however, another side to the question. The relation of +neurosis in childhood to infection of the body is complex. I have said +that with the nervous child a trivial infection may produce symptoms +disproportionately severe. Persistent and serious infection, however, +is capable of producing nervous symptoms even in children who were not +before nervous, and we must recognise that prolonged infection makes a +favourable soil for neuroses of all sorts. The frequency with which +St. Vitus's dance accompanies rheumatism in childhood forms a good +example of this tendency. The child who, from time to time, complains +of the transient joint pains which are called "growing pains," and who +is found by the doctor to be suffering from subacute rheumatism, is +commonly restless, fretful, and nervous. Appetite, memory, and the +power of sustained attention become impaired. Often there is excessive +emotional display, with, perhaps, unexplained bursts of weeping. The +child is readily frightened, and when sooner or later the restless, +jerky movements of St. Vitus's dance appear, the usual explanation is +that some shock has been experienced, that the child has seen a street +accident, has been alarmed by a big dog jumping on her, or by a man +who followed her--shocks which would have been incapable of causing +disturbance, and which would have passed almost unappreciated had not +the soil been prepared by the persistent rheumatic infection. + +The management of the nervous child whose physical health remains +comparatively good is difficult enough, but these difficulties are +increased many times when the physical health seriously fails. To +steer a steady course which shall avoid neglecting what is dangerous +if neglected, and overemphasising what is dangerous if +over-emphasised, calls for a great deal of wisdom on the part both of +the mother and her doctor. + + + + +CHAPTER XIII + +NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS + + +In this chapter I approach with diffidence a subject which is rightly +enough occupying a great deal of attention at the present time: the +instruction of our children in the nature, meaning, and purpose of +sexual processes. It is a subject filled with difficulties. Every +parent would wish to avoid offending the sense of modesty which is the +possession of every well-trained child, and finds it difficult to +escape the feeling that discussion on such matters may do more harm +than good. There is certainly some risk at the present time that, +putting reticence on one side, we may be carried too far in the +opposite direction. The evils which result from keeping children in +ignorance are well appreciated. We have yet to determine the effect +upon them of the very frank and free exposure of the subject which is +recommended by many modern writers. Nevertheless, it must be granted +that it is not right to allow the boy or girl to approach adolescence +without some knowledge of sex and the processes of reproduction. If +nothing is said on such subjects, which in the nature of things are +bound to excite a lively interest and curiosity in the minds of older +children, evil results are apt to follow. Because parents have never +mentioned these subjects to their child, they must not conclude that +he is ignorant of all knowledge concerning them. It is not unlikely +that the question has often occupied his thoughts, and that his +speculations have led him to conclusions which are, on the whole, +true, although perhaps incorrect in matters of detail. Most children, +unable to ask their mother or father direct questions upon matters +which they feel instinctively are taboo, have pieced together, from +their reading and observation, a faulty theory of sexual life. The +pursuit of such knowledge, in secret, is not a healthy occupation for +the child. His parents' silence has given him the feeling that the +unexplored land is forbidden ground. In satisfying his curiosity he is +most certainly fulfilling an uncontrollable impulse, but he has been +forced to be secretive, and to look upon the information he has +acquired as a guilty secret. So far even the best of children will go +upon, the dangerous path. If training has been good, and if the child +has responded well to it, he will go no further. Though he can hardly +be expected to refrain from constructing theories and from testing +them in the light of any chance information which may come his way, he +will instinctively feel that the subject is one best left alone. He +will not talk of it with other boys--not even with those who are older +than himself and whose superior knowledge in all other matters he is +accustomed to respect. We need not be surprised, however, that the +majority of children do not attain to this high standard of conduct, +and that the interest and excitement of exploring the unknown and the +forbidden proves too great. Children will consult with each other +about such matters, and knowledge of evil may spread rapidly from the +older to the younger. In some schools, as is well known, there may +grow up with deplorable facility an unhealthy interest in sexual +matters. On the surface of school life all may seem fair enough, but +beneath, hidden from all recognised authority, lies much that is +unspeakable. If the boy has not been taught to have clean thoughts +upon matters which are essentially clean, if he has not learned to +know evil that he may avoid it, he may not escape great harm. The +fault in us which kept him in ignorance will recoil upon our own +heads. He will maintain the barrier which was erected in the first +place by our own unhappy reticence, and we may find it a hard task to +penetrate behind it and prevent his constant return to secret thoughts +and imaginings or secret habits and practices. Certain physiological +processes come to have for him an unclean flavour which is yet +perniciously attractive. He knows little of the real meaning of sexual +processes or of the great purpose for which they are designed. It is +only that an unhealthy interest becomes attached to all subjects which +are scrupulously avoided in general conversation. In secret he +develops a wrong attitude to all these matters. + +Oliver Wendell Holmes[4] tells us that in religion certain words and +ideas become "polarised," that is to say, charged with forces of +powerful suggestion, and must be "depolarised." + +[Footnote 4: _The Professor at the Breakfast Table_, Oliver Wendell +Holmes.] + + * * * * * + +"I don't know what you mean by 'depolarising' an idea, said the +divinity-student. + +"I will tell you, I said. When a given symbol which represents a +thought has lain for a certain length of time in the mind, it +undergoes a change like that which rest in a certain position gives to +iron. It becomes magnetic in its relations--it is traversed by strange +forces which did not belong to it. The word, and consequently the idea +it represents, is polarised. + +"The religious currency of mankind, in thought, in speech, and in +print, consists entirely of polarised words. Borrow one of these from +another language and religion, and you will find it leaves all its +magnetism behind it. Take that famous word, O'm, of the Hindoo +mythology. Even a priest cannot pronounce it without sin; and a holy +Pundit would shut his ears and run away from you in horror, if you +should say it aloud. What do you care for O'm? If you wanted to get +the Pundit to look at his religion fairly, you must first depolarise +this and all similar words for him. The argument for and against new +translations of the Bible really turns on this. Scepticism is afraid +to trust its truths in depolarised words, and so cries out against a +new translation. I think, myself, if every idea our Book contains +could be shelled out of its old symbol and put into a new, clean, +unmagnetic word, we should have some chance of reading it as +philosophers, or wisdom-lovers, ought to read it--which we do not and +cannot now, any more than a Hindoo can read the 'Gayatri' as a fair +man and lover of truth should do." + + * * * * * + +Now in the minds of many boys and some girls certain words and ideas +connected with certain physiological processes become polarised. It is +the parents' duty to depolarise them. It is a task which cannot well +be deputed to others; nor can much help be derived from books, though +many have been written with the object of initiating children into the +mysteries of sex. No one but a parent is likely to be on sufficiently +intimate terms with the child to enable the subject to be approached +without restraint or awkwardness, and no book can adapt itself to the +varying needs of individual children. An exposition in cold print, or +a single formal lecture on the subject, is apt to do more harm than +good. I have seen instructions to parents to deliver themselves of set +speeches, examples of which are given, which seem to me well +calculated to repel and frighten the nervous child. Still more +dangerous is the advice to make sexual hygiene a subject for class +study. The task requires that parents should be upon very intimate +terms with their children, and on suitable occasions, when this +feeling of intimacy is strong, children should be encouraged to speak +freely and to ask for explanations. By a judicious use of such +opportunities piece by piece the whole may be unfolded. In order that +the child may approach the subject in the proper spirit we may +stimulate interest by a few lessons in Natural History. A child of +eight or ten years of age is not too young to learn a little of the +outlines of anatomy and physiology. If he is told a few bald facts +about the skeleton, about the circulation and the processes of +digestion such as any parent can teach at the cost of a few hours' +study of a handbook, this will lead naturally enough, in later +lessons, to a similar talk upon the excretory organs, reproduction, +and the anatomy and processes of sex, suitable to the individual. To +achieve "depolarisation," there is nothing more efficacious than the +frankness and explicitness of scientific statement, however +elementary. Later a little knowledge of Botany and Zoology will enable +a parent to sketch briefly the outlines of fertilisation and +reproduction. The child may grasp the conception that the life of all +individual plants and animals is directed towards the single aim of +continuing the species. He can be told how the bee carries the male +pollen to the female flower, how all living things habitually +conjugate, the lowest in the scale of development as well as the +highest, and how the fertilised egg becomes the embryo which is +hatched by the mother or born of her. As the child grows older and +understands more and more of these natural processes an opportunity +can be used to make the presentation of the subject more personal. He +can be told that during childhood his own sexual processes have been +undeveloped, but that as he grows older they will awake. That with +their awakening in adolescence new temptations to self-indulgence in +thought or action may assail him, but that these temptations are +delayed by the wisdom of Nature until his understanding has grown and +his man's strength of character has developed. A high ideal of purity +should be set before boy and girl alike, and the conception of sex +from the beginning should be associated in their minds with the high +purpose to which some day it may be put. Before the boy goes to a +boarding-school he should have imbibed from his father the desire for +moral cleanliness, the knowledge of good and of evil, and a cordial +dislike for everything that is sensual, self-indulgent, or nasty. +Talks on such subjects should be very infrequent, but I believe that, +if "depolarisation" is to be achieved, they must be repeated every now +and then during later childhood and in adolescence. To attempt to +impart all this interesting information in a single constrained and +awkward interview is to court failure, or at least to run the risk +that the explanation is not fully understood, so that the child is +mystified, or even offended in his sense of propriety. + +I have dwelt at some length upon this question of sex education, +because it is one of especial difficulty when we have to deal with a +child of nervous inheritance, or with a child in whom symptoms of +neurosis have developed in a faulty home environment. Misconduct in +sexual matters is a sign of deficient nervous and moral control, and +when the conduct in other respects is ill-regulated, the development +of sexual processes must be watched with some anxiety. There are those +who see a still more intimate relationship between errors of conduct +or symptoms of neurosis in childhood and the sexual instincts. + +It is perhaps necessary here briefly to refer to the teaching of +Sigmund Freud of Vienna, because his views have attracted a great deal +of attention in this country and have become familiar to a great part +of the reading public. Freud believes that the origin of many abnormal +mental states and of the disturbances of conduct which are dependent +upon them is to be traced back to forgotten experiences, the +recollection of which has faded from the conscious mind, but which are +still capable of exerting an indirect influence. He regards the +process of forgetting, not as merely a passive fading of mental +impressions, but as an active process of repression, by which the +experience, and especially the unpleasant experience, is thrust and +kept out of consciousness. There thus arises a mental conflict between +the forces of repression and the forces which tend to obtrude the +recollection into consciousness, and at times the energy engendered in +this conflict escapes from the censorship of the repressing forces and +finds vent in the production of abnormal mental states or disorders of +conduct. Thus to take a simple example, a business man who has had a +trying day at the office, on returning home in the evening may succeed +in thrusting out of his consciousness the thought of his +disappointments and worries, yet the disturbance in his mind may show +itself in quarrels with his wife or complaints of the quality of the +cooking at dinner. + +Freud has called attention to the part which the suppressed and +long-forgotten experiences of early childhood play in the production +of neuroses of all sorts at a later date, and he has laid especial +emphasis on sexual experiences as peculiarly fruitful causes of such +disturbances. Those who have embraced Freud's teaching have gone even +farther than he in this direction, and by psycho-analysis--that is to +say, by attempting in intimate conversation to arouse the dormant +memory and lay bare the buried complex, the suppression of which has +produced the conflict in the mind of the sufferer--will seldom fail to +discover the influence of sexual forces and sexual attractions which, +while capable of causing disorders of mind and of conduct, show +themselves only obscurely and indirectly, as, for example, in dreams +or in symbolic form. + +So far as the nervous disorders of children are concerned, much that +is written to-day upon the influence of repressed sexual experiences +may be dismissed as grotesque and untrue. The conclusions to which the +psycho-analyst is habitually led, and which he puts forward with such +confidence, can be convincing only to those who have replaced the +study of childhood by the study of the writings of Freud and his +school. Thus it is common enough to find a mother complaining that her +child of two or three years of age is bitterly jealous of the new baby +who has come to share with him his mother's love and attention. +According to the views of Freud, we are to recognise in this jealousy +an exhibition of the sexual instincts of the older child, who scents a +possible rival for the affections of his mother. Even if we give to +the term sexual the widest possible meaning, it is difficult for a +close observer of children to detect any truth in this conclusion. The +behaviour of the older child to the newly born will be determined +mainly by the attitude adopted by the grown-up persons around him and +by the unconscious suggestions which his impressionable mind receives +from them. If the mother is fearful of what may happen, and refuses to +leave the children alone, she will find it hard to hide from the older +child her conviction that danger is to be apprehended from him. If +this suggestion acts upon his mind, and if the reputation that he is +jealous of the new baby becomes attached to him, he will assuredly not +fail to act up to it, and her daily conduct will appear to prove the +justness of his mother's apprehension. Fortunately, mothers are +commonly able to divest themselves of such fears as these. The older +child is brought freely to the baby to admire him, to bestow caresses +on him, and to speak to him in the very tones of his elders. In a few +days his reputation is established, that he is "so fond of the baby," +and to this reputation too he faithfully conforms. We have seen in an +earlier chapter that constantly and ostentatiously to oppose a child's +will is to produce a counter-opposition which because of its +persistence and vigour appears to have behind it the strongest +possible concentration of mind and power of will. Yet if we cease to +oppose, the counter-opposition which appeared so formidable at once +dissolves, and the difficulty is at an end. We took as an example the +child's apparent determination to approach as near as possible to the +fire, the one place in the room which our fear of accident forbids +him. The difficulty with the new baby is but another example of the +same tendency. If he does not know that the ground is forbidden, if we +do not concentrate his attention on the prohibition, he will show no +particular desire to approach it. His apparent jealousy of his little +brother is the result not of the rivalry of sex, but of bad +management. + +Again, it is occasionally a subject of complaint that children will +apparently dislike their father, that they will shrink from him or +burst into tears whenever he approaches them. There is no need to see +in this the child's jealousy of the father as a rival in the +affections of his mother, which is the explanation proffered by the +school of Freud. Every action and every occupation of the child during +the whole day can be made a pleasure or a pain to him, according to +the attitude of his nurse and mother towards it. Eating and drinking +should be pleasant and are normally pleasant. The same forces which +are sufficient to make every meal-time a signal for struggling and +tears, are sufficient to produce this dislike, apparently so +invincible, to the father of his being. + +Although the nervous troubles of infancy are not commonly due, as +Freud and his numerous followers would have us believe, to suppressed +sexual desires or experiences, it is clear that in the sensitive mind +of the child the reception of a severe shock may have effects long +after the memory of it has disappeared from consciousness. In a +medical journal there was recently recounted the case of an officer of +the R.A.M.C. who all his life had suffered from claustrophobia--the +fear of being shut up in a closed space. By skilful questioning, the +remembrance of a terrifying incident in his childhood was regained. As +a child of five he had been shut in a passage in a strange house by +the accidental banging to of a door, unable to escape from the +attentions of a growling dog. A complete cure was said to follow upon +the discovery that in this incident lay the origin of the phobia. +Nevertheless, observation would lead me to lay the greater stress not +upon any one particular shocking or terrifying experience, but upon +the attitude of parents and nurses in focusing the child's attention +upon the danger, and in sapping his confidence by showing their own +apprehensions and communicating them to him. + +As a method of treatment for neuroses of childhood, psycho-analysis is +not only unsuccessful, it has dangers and produces ill effects which +far outweigh any advantage which may be gained from it. + +There can be no doubt that Freud has exaggerated the part which sexual +impulses play in causing neurosis. It will be sufficient for us to +recognise that for the nervous child the sexual life has especial +dangers, and we should redouble our efforts to prevent his ideas on +the subject becoming "polarised." For the child whose environment has +been well regulated and who has developed strength of character, +self-control, and self-respect, there need be no fear. + + + + +CHAPTER XIV + +THE NERVOUS CHILD AND SCHOOL + + +At the onset of puberty childhood comes to an end, and the period of +adolescence begins. Into these further stages of development it is not +proposed to enter, but it may be well to consider a question which is +apt to present itself for answer at this period: "Should the boy, or +girl, of nervous temperament, or whose development up to this point +has been accompanied by symptoms of nervous disorder, be sent to a +boarding-school?" So long as the child remains at home the home +environment is the force which alone is concerned in moulding his +character. We have seen how plastic the young child is, how imitative, +how suggestible, how prone to form habits good or bad. The diversity +of type shown by the homes is reflected in the diversity of character +and conduct exhibited by the children. The home is the culture medium, +and in no two homes is its composition the same. For each child home +influence remains to a great extent unchanged, and in great part +unchangeable. Its action upon the child is constant and long +sustained. Hence, it is not surprising that the growth of his +character and powers is commonly unequal. At one point we may find a +good crop of virtues, at another a barren tract; and the home +influences which have ripened the one and blighted the other are +calculated by the lapse of time to increase the contrast rather than +to diminish it. + +I suppose it is for this reason that the custom of sending children to +boarding-schools has so firm a hold among us. The boarding-school +forms an environment selected to correct the inequalities which result +from the special action upon the child of individual homes. The life +of a boy in one of our large public schools is well calculated to act +as a corrective in this way not only by reason of its ordered routine +and discipline, but still more because it is affected, perhaps for the +first time, by the strong force of public opinion. It is the strength +of this public opinion which gives to our public schools their +peculiar character and produces their peculiar effects. That which the +schoolboy most despises is what he calls "Bad Form," and he bows down +and worships an idol he himself has set up, the name of which is "Good +Form." Public opinion forms the code of morals observed in the school. +The standard set is commonly not so high as to be very difficult of +attainment. It demands many good qualities. To lie, to sneak, to tell +tales, to bully, to "put on side," are bad form. In some respects the +definition of what is virtuous may be a little hazy. Thus it may be +wrong to cheat to gain a prize, but to copy from one's neighbour only +so much as will enable one to pass muster and escape condemnation is +no great sin. In short, good form demands that a boy should have all +the social virtues: that he should be a good fellow, easy to live +with, and possessed of a high sense of public spirit--good qualities +certainly, though perhaps not those which help to make the reformers +or martyrs of this world. + +The school life is the life of the herd, and to be successful in it +the boy must mingle with the herd, not break from it or shun it. Good +form--if we came to analyse the conception that underlies it--consists +only in a close approximation to the standard pattern; bad form, in +any deviation from it. It is this similarity of type and community of +ideals which makes it so easy for most public-school boys to get on +well with one another. When in after life they are thrown among a set +of men who know nothing of their conception of good form, and whose +training has been on completely different lines, there may be a +corresponding difficulty. + +Now what is true of public-school life is of course also true of the +larger life after schooldays are over for which all education is a +preparation. These qualities of sociability and good sportsmanship +will stand a man in good stead throughout life. Even the most ardent +and active spirit will benefit by being subjected for some years to +this steady pressure of public opinion. The most part will learn from +it good sense, consideration for others, and self-control. As they +pass from the lower forms to the higher in the school they will learn +too to support authority without doing injustice, and to bring the +weight of public opinion to bear upon others. And to all this +training many a man owes his happiness in after life--a happiness +which he could not have secured if his character had been moulded only +by the environment of his home, or by the home in combination with the +less-powerful corrective of a day school. For the nervous child the +passage from home to school life may involve considerable mental +strain. He may be morbidly self-conscious and timid, or, unknown to +himself--because he has as yet no power of self-analysis and has no +opportunities of comparing himself with others--he may have developed +certain eccentricities. In most cases the plunge into school life will +be taken well enough; in a few the little vessel will not right +itself, and proves permanently unseaworthy. No doubt as a rule a +private school will have preceded the public school, and this +gradation should make the entrance to the public school a lesser +ordeal. But it often happens that it is just in the case of the +nervous child that this intermediate stage has been omitted, and that +his thirteenth birthday finds him still in the home circle. + +If the boy's father has first-hand knowledge of life in the lower +forms of public schools, his experience may enable him to form some +estimate of the effect of school life upon the nervous system of his +son. It is when parents or guardians have no such experience of their +own to guide them that mistakes are most liable to be made. I can +myself remember the unhappy state of some solitary and eccentric +schoolfellows of mine who aroused the resentment of "the Herd" by +their behaviour or opinions. If it is clear that the boy has a +peculiar temperament and is likely to suffer in this way, some _via +media_ must be found. The home has failed so that he must leave home +and come under the influence of some one who understands the nature of +the difficulty and can adapt the boy to school life. A change of +environment of this sort as a preliminary to the public school is +often all that is needed. If his age permits, every effort should be +made in this way to obtain for the nervous child who has developed +peculiarities or faults the benefits of a public-school education. + +Some types of nervous children will show immediate improvement when +they go to school. The boy who is passionate and disobedient, and +whose parents cannot control him, is best at school. Boys who, from +being much with grown-up people, have become too precocious and have +acquired the habits and tastes of their elders, will dislike school at +first, but it will do them good. Their fault shows that they are quick +to learn and sensitive to the influences of others, and they will soon +adapt themselves to their new surroundings. Boys who are dreamy and +imaginative, who early adopt a "specialist" attitude towards life, +who, however ignorant they may be of everything else, cultivate a +reputation for omniscience in some particular subject, such as +Egyptology, astronomy, or the construction of battleships, are usually +nervous boys whose symptoms will disappear at school. Where undue +timidity, phobia, or habit spasm is present, the question is more +difficult to decide. Every individual case must be studied as a whole, +and our object should be not unnecessarily to deprive the boy of the +wholesome training of public-school life. + +There are parents who from sheer ignorance add to the difficulties +which the boy encounters in going to school. Failure to appreciate +very small points may cause unnecessary suffering. To be the only boy +in the school to wear combinations is not a distinction that any new +boy craves, however strong his nerves may be. A friend of mine still +relates with feeling how, twenty years ago, he arrived at school with +shirts which _buttoned_ at the neck! At night when every one else in +the dormitory was asleep he sat for hours on his bed, miserable beyond +words, removing the buttons and doing his best in the dark to bore +buttonholes which would admit what every other boy in the school +had--a collar stud. + +With girls perhaps this question of fitness for school life does not +arise in so urgent a way. Girls are usually older when they go to +school, and girls' schools are perhaps less terrifying and more like +home. There is, however, one important point which should be borne in +mind. The date of the onset of puberty varies much in both sexes. If +the boy grows to a great hulking fellow at fourteen, and even displays +a desire secretly to borrow his father's razor, he is at no particular +disadvantage as compared with his fellows. He is so much bigger and +stronger than the others that he may thereby early enjoy the +distinction of playing at "big side," or of getting a place in the +school Eleven. He is probably much envied by those of the same age +who, with the aid of their youthful aspect, can still occasionally +extract compensation by inducing the railway company to let them +travel to school at half fare. But with girls it is different. Many at +fourteen or fifteen are children still; some are grown up, with the +tastes, feelings, and attraction of maturity. Those who have developed +fastest are often, for that very reason, kept backward in school +learning. Often they are nervously the least stable. Now that large +schools for girls on the model of our public schools are become the +fashion, such precociously developed and nervously unstable girls are +apt to find themselves in the very uncongenial society of little girls +of twelve or thirteen. The elder girls commonly hold aloof, while +mistresses are apt to view this precocious development with +disapproval, and to attempt to retard what cannot be retarded by +insisting that the young woman has remained a child. I remember being +called in consultation by a surgeon who had been asked to operate for +appendicitis upon a girl of fourteen. I found a tall, well-grown girl, +with an appearance and manner that made her look four years older. I +could find no signs of appendicitis, but I learned from her that she +had been for three months at a large girls' school, and that in a few +days' time her second term was due to begin. As we became friends, she +agreed that her appendicitis and her resolve not to return to school, +where she was unhappy, were but different ways of saying the same +thing. She was an only child who had travelled a great deal with her +parents, had found her interests in their pursuits, and had grown +backward in school work. The little girls with whom she was expected +to associate seemed to her mere children. The elder girls did not want +her friendship, and snubbed her. I prescribed a change to a small +boarding-school with only a few girls, where age differences would not +matter so much, and where she could make friends with girls older than +herself, though not more mature. + +Into their school life we need not follow the children. Happily the +time is past when schoolmasters and schoolmistresses were incapable of +understanding their charges, and confounded nervous exhaustion with +stupidity or timidity with incapacity. + +And so we come back to the point from which we started: + +The nervous infant, restless, wriggling, and constantly crying! The +nervous child, unstable, suggestible, passionate, and full of nameless +fears! The nervous schoolboy or schoolgirl prone to self-analysis, +subject-conscious, and easily exhausted! And how many and how various +are the manifestations of this temperament! Refusal of food, refusal +of sleep, negativism, irritability, and violent fits of temper, +vomiting, diarrhoea, morbid flushing and blushing, habit spasms, +phobias--all controlled not by reproof or by medicine, but by good +management and a clear understanding of their nature. + +The hygiene of the child's mind is as important as the hygiene of his +body, and both are studies proper for the doctor. Neuropathy and an +unsound, nervous organisation are often enough legacies from the +nervous disorders of childhood. + + + + +INDEX + + +Abdomen, prominent + +Abdominal symptoms of neurosis + +Accent, local, facility with which acquired + +Acetone, in breath and urine during cyclic vomiting + +Acidosis, accompanying cyclic vomiting + +Action, imitativeness of + liberty of, in early childhood + +Activities in the nursery + not to be restrained + without intervention of grown-up people + wonderful nature of + +Adenoid vegetations, night-terrors aggravated by + removal of, in treatment of enuresis + +Adolescence, and education on sexual matters + +Adults, child in relation to the society of + +AEsthetic 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 + +Anaemia, 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 anaemia + +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 + +Defaecation, 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, aetiology 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 + +Faeces, 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 + aetiology 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 + aetiology 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'. + + + + + +End of Project Gutenberg's The Nervous Child, by Hector Charles Cameron 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