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 | 18
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]

[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 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. 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.

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.

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, | Symbol: minim x. [10 minims]
Aq. menth. pip., ad   | Symbol: dram 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 main 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.

[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]

[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 Cholera

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."

[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, diarrhœa, 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, 151

Abdominal symptoms of neurosis, 153

Accent, local, facility with which acquired, 17

Acetone, in breath and urine during cyclic vomiting, 86

Acidosis, accompanying cyclic vomiting, 85

Action, imitativeness of, 19
liberty of, in early childhood, 22

Activities in the nursery, 98
not to be restrained, 23, 24, 98
without intervention of grown-up people, 99
wonderful nature of, 24

Adenoid vegetations, night-terrors aggravated by, 136
removal of, in treatment of enuresis, 93

Adolescence, and education on sexual matters, 169, 175

Adults, child in relation to the society of, 36, 38

Æsthetic sense, in early childhood, 48

Affection, in the child, 48

Air hunger, in cyclic vomiting, 86

Air swallowing, habitual action of, 79

Albuminuria, associated with faulty posture, 152
cause of, in neuropaths, 152

Allimentary disturbances, symptom of, 157

Alkali, in treatment of cyclic vomiting, 87

Anæmia, of neuropaths, 152

Anorexia nervosa, 50
A case illustrating, 50

Apnœa, fatal cases of, 83
following burst of crying, 82
twitching of facial muscles in, 83

Appetite, emotional states affecting, 52
loss of, 51
case illustrating, 51
causes and characteristics, 56, 62
treatment, 62
means of stimulating, 53
nature of the sensation of, 52

Apprehension, causes of, 28
growth of neuroses in atmosphere of, 75

Artificial feeding, 109, 113

Aspirin, 71

Asthma, treatment of, 166

Attention, child's love of attracting, 32, 35, 59
examples of, 33, 39

Authority, delight in defying, 43-46
over-exercise of, by parents, results of, 42, 43, 45

Babies. See Newborn Baby

Backward development, 56, 146
signs of, 56

"Bad form," 183

Bad habits, 77-80

Bath, baby's first experience of, 105, 106

Bed, dislike of, 28
how overcome, 28, 29
efforts to resist preparation for, 64, 65, 66

Bedroom, airing and temperature of, 69

Bedtime, 64, 66
management at, 65, 66

Bed wetting. See Enuresis

Behaviour. See Conduct

Bladder, hydrostatic distension of, for enuresis, 92, 93

Boarding-schools, object of, 183

Bodily ailments, and instability of nervous control, connection
between, 120
See also Disorders

Body,
and mind, development of, 120, 121
development of, 146
environment influencing, 5
effect of mind on, 51
gradual alterations in the shape of, 146
infantile characteristics in later childhood, 145, 146

Bone, and muscle, changes in, in infantile children, 148

Books,
child's attitude towards, 99
educative value of, 99, 100
kinds most suitable, 99, 100

Brachial nerve, pressure causing tetany, 81

Breast-feeding,
best time for, 109
causes of failure in, 108
observations on, 106
See also Lactation

Breath-holding, 81, 82
action during, 84
fatal cases of, 83
phenomena of, 82

Bromides, administration of, 71
to newborn baby, 110, 111

Cajoling, futility of, 26

Calcium bromide, in treatment of spasms, 84

Calcium metabolism, disturbance of, 82

Care, ill effects of excess of, 163

Carpo-pedal spasm, 81

Catarrhal infections, 155
connection of rheumatism with, 155

Cerebral anæmia, 140

Cerebral circulation, stagnation of, 140

Cerebral exhaustion. See Mental Exhaustion

Cerebral functions,
rapid growth of, 5
unstable in the child, 6
See also Mental

Character,
formation of, 126
during school life, 184, 186
home influence in the development of, 182, 185, 186
ideals of, how inculcated, 125

Children's parties, disadvantages of, 102

Chloral, administration of, 71
to newborn baby, 110, 111
in treatment of spasms, 84

Chorea, 155
and rheumatism, association between, 155
symptom of cerebral irritability, 156
treatment of, 156

Chvostek's sign, characteristics and nature of, 81

Circulation, cerebral,
stagnation of, 140
nervous control of, 140

Claustrophobia, 180

Clothing,
kind suitable, 69
new, child's delight in, 48

Coaxing, 67
futility of, 26

Cold douches, improving vasomotor tone, 154

Coldness of extremities, 141

Conduct,
control of, factors in, 33, 129
errors of, and sexual instincts, 176
control of, 39
correction of, 127
due to faults of management, 127
in neuropathic children, 126
excessive introspection influencing, 139
ideals of, how inculcated, 125
influence of environment on, 131
influenced by suggestion, 13
mother's influence on, 11
of neuropaths, 132, 133
perverse, 45
suggestion in the control of, 130

Constipation, 12
mental causes of, 30, 80
negativism in, 80
perversion of suggestion a common cause of, 30
suggestion in relation to, 80

Constitution, delicacy of, 161

Convulsions, fatal cases of, 83
generalised, 81

Convulsive disorders, 149, 150

Cough, nervous, 73

Counter-opposition, child's opposition growing with, 60, 67, 179

Crying, constant, 54, 67
formation of habit of, 115
in emotional and excitable children, 82
management of, 68
mechanism of, 149
phenomena of, 67
purposeful, 68

Cyclic or periodic vomiting. See Vomiting

Day-dreams, indicating nervous temperament, 137

Deceit, 123, 124

Defæcation, inhibition of, 11, 12, 13
painful, 2

Delicacy of constitution, 161

Delirium, tendency to, 161, 162

Depolarisation of ideas, 172

Depression, recurrence of periods of, 61

Dexterity, lack of, 56
manual, advantages of, 122
toys developing, 96

Diaphragm, spasm of, 82

Diarrhoea, mucous, 142

Diet, likes and dislikes for articles of, 25
opposition to, 25
of newborn child, changes in, 113
See also Food

Digestion, emotional states affecting, 52, 53

Digestive disorders, mental causes of, 51, 52, 62

Digestive neuroses, 50

Digestive system, symptoms of extreme sensibility of, 141

Dirt eating, 80

Discipline, 43
in later childhood, 118
in the school, 183
misdirected efforts at enforcing, 44
severe, effects of, 119

Dishonesty, 127

Disobedience, 43, 45
growth of, 42
habit of, 59
personality and, 58
perverse attitude of, 34
reproof and coaxing causing, 61

Disorders, ætiology of, 14
associated with neurosis, 145
common, 140-141
environment as cause and cure of, 142
of neuropaths, 145-159
treatment of, 142
trifling, 162

Diuresis, excessive, 141

Doll, child's care of, an example of imitativeness, 23
educative value of, 98

Douches, cold, improving vasomotor tone, 154

Dover's powder, 72

Dreams, 70
nature of, indicating nature of mental unrest, 137

Drugs, in sleeplessness, 70, 71

Ductless glands, in relation to infantile characteristics, 147

Dullards, 149

Dyspepsia, complications of, 54
course and effects of, 54
mental aspects of, 53
nervous symptoms of, 53, 54
symptoms in newborn infant, 116
treatment, 63

Early childhood, care during, 105
impulse of opposition in, 35
love of power in, 32, 36

Early childhood, nervousness in, 104
reasoning power in, 40
three common neuroses of, 74
toys, books, and amusements in, 96
See also Newborn Baby

Education, aim of, 118-120
by games and toys, 96
on sexual matters, 169

Educative value, of books, games, and toys, 98-100

Emotional states, appetite affected by, 52
causing spasm, 83
management of, 82
of neurotics, exaggeration of, 131
physical disturbances due to, 53, 54
producing laryngismus stridulus, 82

Emotional storms, 68

Endocrine glands, 147

Enuresis, 81, 89
causal factors in, 89, 90
characteristics and peculiarities of, 90-92
condition of urine during, 93
mental aspects of, 95
mistakes in treatment of, 94
perversion of suggestion as cause of, 89
removal of tonsils in, 92, 93
treatment, essentials in, 94
hypnotic suggestion in, 95
methods of, 92-93

Environment, body moulded and shaped by, 5
change of, beneficial effects of, 13
effect in developing child's powers, 22
effect on common disorders, 142
errors of, and neuropathic children, 126
essentials of, 39
faulty contact with, in neuropathic children, 138
for neuropaths, 132
influence on conduct in later childhood, 131
influence on mental processes, 10
influence on personality, 24, 25
irritating nature of the adult mind in, 36, 38
of the home, reflected in the child, 182
of school life, 183-186
stimulus of, 22
susceptibility to influences of, 25, 31

Epilepsy, cyclical character of, 61

Evil, inborn disposition to, 130

Excitable children, management of, 82

Exercise, sleep in relation to, 69

Exhaustion. See Mental Exhaustion

Expostulation, frequent, bad effects of, 124, 125
See also Reproof

Expressions, to attract attention, 39

Facial muscles, twitching of, 81
associated with apnœa, 83

Fæces, incontinence of, 92

Fainting fits, 140
cause and characteristics, 140
control of, 141
of neuropaths, 152

Fatigue, mental, physical, and visceral, 143

Fats, lowered tolerance to, 87

Faults, correction of, 127
not corrected by too frequent reproof, 124, 125

Fear, 39
causes of, 28
phenomena of, 134, 135
prominent psychical symptom of neuropathic children, 132, 133
treatment of, 135

Feeding, 55
artificial, 109, 113
factors in, 57, 58
of newborn infant, regularity in, 116

Fertilisation, method of imparting knowledge of, 174

Food, force of suggestion in relation to, 25-27
healthy desire for, 62
likes and dislikes for, 25
how overcome, 26
phenomena of the desire of, 52
refusal of, 35, 50
nervous causes of, 52
persistent, factors encouraging, 57
suggestion in relation to, 57, 58
treatment of, 26, 55, 62

Force and cajoling, futility of, 26

Freud, teaching of, 176

Functional disturbances, in combination with organic disease, 4

Gait, peculiarity of, 74

Games, educative value of, 96, 98

Gastric disturbances, 54

Gastric juice, psychic secretion of, 52

Gastric symptoms, of neurosis, 153

Gastro-intestinal derangement, causes of, 141
environment as cause and cure of, 142

Gentleness, 119
inculcation of, 129

Girls' schools, 188

Glottis, spasm of, strong emotion causing, 82

"Good form," 183, 184

Grasping habit, reproof in relation to, 21

Growing pains, 167

Habit spasms, age of appearance of, 74
cause of, 74
definition of, 73
examples of, 73
spread of, 75
suggestion in relation to, 74
treatment of, 76

Habits, regulation of, 30
suggestion in relation to, 30

Habitual actions, infant's pleasure in, 77
mental unrest in relation to, 77
of the parent, reproduction in the child, 75
varieties and characteristics, 77

Habitual wakefulness, 70

Hands, control of movement of, 19, 22
expressionless, 56

Happiness and contentment, of child when playing alone, 96

Headache, periodic. See Migraine

Heat and cold, newborn baby in relation to, 106

Heat and flushing, sudden sensations of, 141

Heredity, and temperament, 10
and type of child, 31
nervous disorders in relation to, 5

Home influence, in development of character, 182, 185, 186
reflected in the child, 182

Hunger, of the newborn baby, 105, 109

Hypnotic suggestion, in treatment of enuresis, 95

Hypnotics, 70, 71

Hysteria, 158
age of appearance of, 158
suggestion in relation to, 32
symptoms of, 158

Hysterical girls, characteristics of, 32

Ideals, inculcation of, 118-119

Ideas, polarisation and depolarisation of, 172

Illness. See Sickness

Imagination, abnormal, correction of, 138
child's stories and tales in relation to, 137, 138
developed by toys, 98

Imitativeness, age at which apparent, 16
extent of, 23
illustration of, 17, 23
lack of, 56
of action, 19
of speech, 17, 18
tell-tale child an illustration of, 18

Incontinence of urine, 89-95

Incorrigible children, 129

Infantile characteristics, 146
ductless glands in relation to, 147
nervous system in relation to, 149, 150

Infective disorders,
convalescence from, 157
producing nervous symptoms, 167
relation of neurosis to, 167

Inflammatory reactions, 147

Insomnia. See Sleeplessness

Intellect, compared with physique, 120

Intelligence, in early childhood, 40, 41, 42

Intestinal disturbance, 54
of neurosis, 153
symptom of, 157

Intoxications, violent reaction to, 142

Introspection, and neuropathic children, 138
excessive, evidences of, 139
influencing conduct, 139

Irritation, child to be free from, 40

Joint pains, 167

Kindergarten school, artificial symbolism of, 24

Kindness, inculcation of, 129

Lactation,
care of child during, 106, 109
care of mother during, 110
causes of failure in, 108
establishment of, 106, 107
tongue-tie in relation to, 12

Laryngismus stridulus. See Breath-holding

Later childhood,
infantile characteristics in, 146
management in, 117-130
mental backwardness in, 146

Likes and dislikes, 25

Lordosis, 151
and neurosis, 151
producing albuminuria, 152

Manual dexterity, advantages of, 122

Massage, improving tone of muscles, 154

Medicines, sensitiveness to, 26

Melancholy children, 157

Mental aspects, of digestive disorders, 51-54
of enuresis, 95
of management in early childhood, 31

Mental backwardness,
and infantile characteristics, 146
in later childhood, 146

Mental disturbances,
cyclical character of, 61
indicating neuropathic tendencies, 132, 133
irregularities of sleep due to, 68
psycho-analysis of, 177, 178

Mental exhaustion,
during convalescence from infective disorders, 157
easily produced in nervous children, 143

Mental irritability, chorea a symptom of, 156

Mental life of the child, 101

Mental power,
active before beginning of speech, 40
in early childhood, 40

Mental processes, development of, 5, 22, 23, 50
age at which most apparent, 16
in later childhood, 117
effect of unconscious suggestions on, 29
heredity in relation to, 10
influence of environment on, 10, 22

Mental training, 122
compared with physical training, 120
objects and advantages of, 122, 126

Mental unrest,
avoidance of, 67
crying in relation to, 67
digestive disturbances due to, 62
growth of neuroses in atmosphere of, 75
habitual actions in relation to, 77
in the adult, 7
in the child, 6, 7
negativism due to, 60
of newborn infant, effects of, 107
See also Nervous Unrest

Micturition,
functional disorder of, 30
negativism in, 81
regulation of, 30
See also Enuresis

Migraine,
periodic vomiting associated with, 85
symptom of nervous exhaustion, 87

Mind,
and body, development of, 120, 121
effect on the body, 51
vigour of, in relation to that of body, 120

Money, theft of, 127

Montessori system of training, 20, 23, 121

Moral degeneracy, 126

Moral standard of school life, 183

Moral training, 123
importance and effects of, 120
negative virtues and, 124
objects and advantages of, 123, 126
parents' responsibilities in, 123, 124

Morals, public opinion forming code of, 183

Morbid introspection, 139

Mothers,
ability and inability to manage children, 8
attitude in regard to temperament of child, 10, 11
care of, during lactation, 110
conduct of child influenced by, 11
inability to understand nature of child's disorders, 5
influence of, on tone and manner of speech, 17
mental environment of child created by, 8
personality of, 7
relation to the child, 101

Motionless children, 157

Mouth, habit of conveying everything to, cause of, 19

Movements,
precision of, 20
purposive, development of, 19, 21
self-command of, 21

Muscular atrophy, and neurosis, 151

Muscular system,
changes in infantile children, 148
weak development of, 151

Muscular tone, how improved, 154

Myopathy, primary, 151

Nasal obstruction
and failure of lactation, 12, 108
night-terrors aggravated by, 136

Natural history, sexual matters taught by, 174

Naughtiness, child's delight in, 45

Naughty, use of the term, 44

Negative virtues, and moral training, 124

Negativism, 3, 12, 13
cause of, 60, 61
characteristics, 50
factors developing, 56
in constipation, 80
in micturition, 81
spirit of, 45
treatment of, 60
want of sleep depending on, 64

Nerve centres, controlling movement, development of, 21

Nervous control, instability of, connection between bodily ailments
and, 120

Nervous cough, 73

Nervous disorders,
and psycho-analysis, 177, 178
common, causes, characteristics, and treatment, 140-142
frequency of, 50

Nervous exhaustion, cyclic vomiting and migraine symptoms of, 87

Nervous instability, stigma of, 140-142

Nervous system, abnormal in children, 149
in relation to cyclic vomiting, 85
increased irritability of, 81
infantile characteristics of, 149

Nervous unrest, environment in relation to, 142
factors increasing, 61
manifestations of, 73
recurrence of periods of, 61
symptoms of, 6, 7
See also Mental Unrest

Nervous vomiting. See Vomiting

Nervousness, and digestive disorders, 53, 54
and neuropathy, 132-135
in early infancy, 104
in older children, 131-144
parents' attitude causing, 31

Nettlerash, 161

Neurasthenia, 157

Neuropathic children, common symptoms of, 140-144
conduct of, 133
faulty contact with environment in, 138
fear the prominent symptom of, 133
introspection and self-consciousness of, 138
management of, 150
training of, 126

Neuropathic tendencies, evidence of, in older children, 133

Neuropaths, adult, 143
faulty management in child life leading to, 2, 14
phenomena of, 132
phobias of, 143
selection of suitable environment for, 132, 133
symptoms of, 7

Neuroses, and psycho-analysis, 177, 180
association of albuminuria with, 153
constipation frequently due to, 80
examination of, 82
growth in atmosphere of unrest and apprehension, 75
relation of, to infection of the body, 167
treatment of, 153

Neurotics, and physique, 145, 151
characteristics, 131, 132
exaggeration of emotions of, 131

Newborn baby, administration of sedatives to, 110
artificial feeding of, 109, 113
breast feeding of, 106, 107
case of, 105, 109, 114, 115
effect of mental unrest on, 107
first impressions of, 104
formation of habits of sleep and crying in, 115
heat and cold in relation to, 106
hunger of, 105, 109
induction of the sucking movements of, 106
of nervous inheritance, 105
personality of, 104
prevention of restlessness and crying, 114, 115
reduction of sense stimuli in, 105
reflex action of sucking in, 108
sense of taste of, 113
symptoms of dyspepsia in, 116
times of feeding, 116
weaning of, 113, 114

Night-terrors, aggravation of, 70, 136
causes of, 135
of neuropathic children, 134

Nursery, activities in, child's interest in, 22-23
importance of child's being alone
in, 36, 38, 96, 99, 101
observations in, 16

Nursery life, advantages of, 9

Nursery psycho-therapeutics, 15

Nurses, ability and inability to manage children, 9
influence of, on tone and manner of speech, 17
mental environment of child created by, 8
personality of, 7

Nursing, during sickness, 166
of the newborn infant, 105-115

Obedience, 49
and perverse pleasure, 34
growth of, 42

Obsession of bed wetting, 89, 91

Opposition, 61
and counter-opposition, 67, 179
during sickness, 160
force of, factors influencing development, 60
habit of, 59
impulse of, 35
love of, in early childhood, 59, 60
to food, 25

Organic disturbance, in combination with functional trouble, 4

Pain, frequent loss of sense of, in neuropaths, 138, 139

Pallor, 152
sudden attacks of, 141

Palpitation, example of visceral fatigue, 143

Parathyroid glands, function of, 147

Parents,
and children, conflict between, 43, 44
and silence on sexual matters, 170
habitual actions of, reproduced in the child, 75
mental attitude of, in relation to conduct, 31
over-exercise of authority by, results of, 42, 43, 45
responsibilities in moral training of child, 123, 124
suggestions unconsciously conveyed by, evil results of, 31, 164, 166

Parties, disadvantages of, 102

Patient, temperament of, physician in relation to, 4

Pelvis, development of, 146

Peripheral nerves, increase in irritability and conductivity of, 81

Personal adornment, delight in, 48

Personality,
and disobedience, 58
child's own conception of, 24, 129
environment influencing, 25
in early childhood, 32, 165
of newborn baby, 104

Perspiration, abundant, sudden attacks of, 141

Phobias, 14
characteristics and varieties, 134, 135
frequency of, 134
treatment of, 135

Physical defects, accompanying neurosis, 145, 151

Physical disturbances, due to emotion, 53, 54

Physical exercise, lack of, causing want of sleep, 69

Physical fatigue, easily produced in nervous children, 143

Physical phenomena of neuropaths, 132

Physical training, 121
objects and advantages of, 121, 122, 126

Physician,
and the temperament of his patient, 4
examination by, 2, 3, 13
diagnosis by, 2, 3, 13
difficulties of, 4

Physique, intellect compared with, 120

Pica and dirt eating, 80

Picture books,
educative value of, 100
kinds most suitable, 99, 100

Play,
happiness of child during, 96
in the nursery, 36, 37
with grown-up persons, 36, 38

Pleasure, sense of, in early childhood, 48

Polarisation of ideas, 172

Postural albuminuria, 152

Posture, faulty, 161, 162
prevention of, 154

Power, child's love of, 32, 59

Precision of movement, development of, 19, 96

Psycho-analysis,
dangers of, 180
observations on, 176, 177

Public schools, character and effects of, 183

Punishment,
deserved and undeserved, 126
frequent, disadvantages of, 47
observations on, 39, 46

Purity, inculcation of high ideals of, 175

Purposive movements, earliest,
cause of, 19
encouragement of, 24

Pyloric spasm, 112

Pyrexia, 88
organic disease in relation to, 88

Rational hygiene, 5

Reasoning power, 40
active before advent of speech, 40
factors influencing development of, 40, 41, 117, 118

Regulation of habits, 30

Repression, by older children of younger, 47

Reproduction, method of imparting knowledge of, 174

Reproof, 20, 21, 24
cases in which useless, 60, 124
causing disobedience, 61, 124
effects of, 33, 36, 47, 124
extreme sensitiveness to, 46
perverse pleasure of, 34
too frequent repetition of, futility of, 44, 45, 47, 60, 124, 125

Restlessness, during sickness, 160

Rewards, use and dangers of, 48

Rheumatism, 155
and chorea, association between, 155
characteristics in childhood, 156
subacute, 167
treatment of, 156

Rickets,
mental and intellectual condition in, 120
in infantile children, 148
occurrence with spasmophilia, 82

Right and wrong, appreciation of, in early childhood, 42

Round shoulders, 151

St. Vitus's dance, 167

Salts, excretion of, 147

School life, 182, 184
and sexual matters, 171, 175
moral standard of, 183
moral training and, 123
moulding of character during, 184
of boys, 183-187
of girls, 188

Schools, public, character and effects of, 183

Scoliosis, prevention of, 154

Secretions, anomalies of, 141

Self, child's conception of, 48

Self-conscious children, complaints of, 139

Self-consciousness, of neuropathic children, 138

Self-discipline, development of, 125, 126

Self-education, in the nursery, 96

Self-feeding, 55

Self-preservation, morbid instinct of, 134

Self-sacrifice, not to be expected in early childhood, 48-49

Sensations,
acuteness of, 69
bodily, of neuropaths, 138

Sense perception, of neuropaths, 132

Sense stimuli,
cultivation of perception of, 23
in newborn babies, 105

Sexual matters,
education on, 168
method of, 174
errors of conduct and, 176
parents' silence in regard to, 170
psycho-analysis in relation to, 177, 178
school life in relation to, 171, 175

Sickness, 160
evil effects of suggestions unconsciously conveyed by parents
during, 164, 166
management during, 160, 163
nurse and mother during, 166
opposition during, 160
temperature during, 161
therapeutic measures in, 164
therapeutic procedures concentrating child's mind on his symptoms, 163

Sleep, estimation of the amount of, 136
force of suggestion in relation to, 27, 28
formation of habit of, 115
light and broken, cause of, 68, 136, 137
of newborn infant, 114
sound, beneficial effects of, 71

Sleeping attire, 69

Sleeplessness, breaking of the habit of, 70
causes and characteristics, 64
drugs in, 70, 71
in older children, 136
lack of physical exercise causing, 69
suggestion in relation to, 27, 28, 70
treatment of, 67, 70, 137

Sleep-walking, 137

Snatching, habit of, 20

Spasmophilia, 81
ætiology of, 81
drugs in treatment of, 84
occurrence of rickets with, 82

Spasms, control of, 84
fatal, 83

Speech, beginnings of, 17, 18
facility with which local accent is acquired, 17
imitativeness of, 17, 18
infant's reasoning power present before advent of, 40
influence of nurses and mothers on tone and manner of, 17

Spinal deformity, prevention of, 154

Spinal muscles, atrophy of, 151

Spoon feeding, 113

Status catarrhalis, 150

Status lymphaticus, 150

Story-telling, 99, 100

Sucking movements, of newborn child, induction of, 106
see also Lactation

Suggestion, and habit spasms, 74
appetite in relation to, 52
bed wetting in relation to, 89
bodily habits in relation to, 30
characteristics, 24
conduct influenced by, 13, 130
constipation in relation to, 80
effect on mental processes, 29
food in relation to, 25
force of, on child's mind, 27, 75
hysteria in relation to, 32
perverse influence of, 29, 30
bad habits due to, 89, 90
causing constipation, 30
want of sleep depending upon, 64
refusal of food in relation to, 57, 58
sleep in relation to, 27
susceptibility to, 29, 57
unconsciously conveyed by parents, evil results of, 31, 164, 166

Suicide, 52

Suspicions, aroused in the child, 57, 58

Syncopal attacks, causes and characteristics, 140, 141

Tactile sensation. See Touch

Taste, perversion of, 26, 57
sensations of, 25
how controlled, 26
sense of, in newborn infant, 113

Teething convulsions, 148

Tell-tale child, characteristics, 18

Temperament, diversity of, 10
heredity and, 10
mother's attitude in relation to, 10, 11
of the patient, physician in relation to, 4

Temperature, during sickness, 161
inexplicable rises in, 88

Terror, causes, of, 28

Tetany, liability to, in increased irritability of nervous system, 81
pressure to brachial nerve causing, 81

Theatres, disadvantages of, 103

Theft, 52, 127

Therapeutic conversation, 124, 125

Thigh rubbing,
avoidance of, 78
characteristics, 78
habitual action of, 78

Thorax, development of, 146

Thumb sucking, 78, 79
persistence of the habit, 79

Tongue-tie, in relation to lactation, 12

Tonics, 155

Tonsils, removal of, in treatment of enuresis, 93

Touch, sense of,
cultivation of, 23
early development of, 19, 20
organs with greatest development of, 19

Toys,
child's interest in, 36
educative value of, 96, 98
kind most suitable, 97

Training, early, importance and object of, 2

Trousseau's sign, nature and production of, 81

Truthfulness, 123, 124
inculcation of, 128

Twitching of facial muscles, 81, 83

Tyranny of tears, 116

Unkindness, habitual, of children to others, 129

Untruthfulness, 126
over-exercise of authority encouraging, 43

Urine,
condition in enuresis, 93
incontinence of, methods of treatment, 92, 93
See also Enuresis
increased secretion of, 141
irritation of, 148

Vasomotor instability,
conditions indicating, 140, 141
in neuropaths, 152

Vasomotor tone, how improved, 154

Virtuous, definition of the term, 183

Visceral fatigue, easily produced in nervous children, 143

Vocabulary, 18

Voice, tone of, 17

Voluntary movements, development of cerebral centres controlling, 19

Vomiting, cyclic, 50, 55
ætiology of, 85
age at which it occurs, 86
case illustrating, 51
causes and characteristics, 62, 86
class of child affected by, 87
condition of the child during, 86
frequency of attacks, 86
migraine in association with, 85
nervous system in relation to, 85, 87
treatment of, 62, 63, 87

Waking states, 136

Weaning, difficulty in, 113, 114

Will, strength of, absence in childhood, 34

Work and play, differentiation between, 123

Writing, correct posture during, 155

Transcriber's Notes

The following typographical errors were corrected:
Page 4: 'sensisive' changed to 'sensitive'.
Page 48: 'self-abnegnation' 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'.