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

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

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

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

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



CHAPTER IV

WANT OF SLEEP

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

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

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

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

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

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

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

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

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

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



CHAPTER V

SOME OTHER SIGNS OF NERVOUSNESS

HABIT SPASM

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

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

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

AIR SWALLOWING, THIGH RUBBING, THUMB SUCKING

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

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

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

PICA AND DIRT EATING

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

CONSTIPATION

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

BREATH-HOLDING AND LARYNGISMUS STRIDULUS

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

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

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

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

MIGRAINE AND CYCLIC VOMITING

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

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

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

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

UNEXPLAINED PYREXIA

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



CHAPTER VI

ENURESIS

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

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

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

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

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

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

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

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

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

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

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

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

(d) Medicinal.—(i) Belladonna. (ii) Thyroid extract.

(e) By Suggestion.—(i) By simple suggestion. (ii) By hypnotic suggestion.

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

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

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

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

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



CHAPTER VII

TOYS, BOOKS, AND AMUSEMENTS

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

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

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

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

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

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

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

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

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



CHAPTER VIII

NERVOUSNESS IN EARLY INFANCY

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

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

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

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

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

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

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

Chloral hydrate, gr. i. [1 grain]

Syrup, M x. [10 minims]

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

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

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

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

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

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

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

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

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

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

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



CHAPTER IX

MANAGEMENT IN LATER CHILDHOOD

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

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

[Footnote 2: The Principles of Rational Education, by Dr. C.A. Mercier.]

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

PHYSICAL TRAINING

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

MENTAL TRAINING

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

MORAL TRAINING

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