THE NERVOUS CHILD



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



THE

NERVOUS CHILD

BY

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

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

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



First Edition 1919 Second Impression 1930



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



PREFACE

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

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

H.C.C.

March 1919.



CONTENTS

CHAP. PAGE

I. DOCTORS, MOTHERS, AND CHILDREN 1

II. OBSERVATIONS IN THE NURSERY 16

III. WANT OF APPETITE AND INDIGESTION 50

IV. WANT OF SLEEP 64

V. SOME OTHER SIGNS OF NERVOUSNESS 73

VI. ENURESIS 89

VII. TOYS, BOOKS, AND AMUSEMENTS 96

VIII. NERVOUSNESS IN EARLY INFANCY 104

IX. MANAGEMENT IN LATER CHILDHOOD 117

X. NERVOUSNESS IN OLDER CHILDREN 131

XI. NERVOUSNESS AND PHYSIQUE 145

XII. THE NERVOUS CHILD IN SICKNESS 160

XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS 169

XIV. THE NERVOUS CHILD AND SCHOOL 182

INDEX 191



THE NERVOUS CHILD

CHAPTER I

DOCTORS, MOTHERS, AND CHILDREN

There is an old fairy story concerning a pea which a princess once slept upon—a little offending pea, a minute disturbance, a trifling departure from the normal which grew to the proportions of intolerable suffering because of the too sensitive and undisciplined nervous system of Her Royal Highness. The story, I think, does not tell us much else concerning the princess. It does not tell us, for instance, if she was an only child, the sole preoccupation of her parents and nurses, surrounded by the most anxious care, reared with some difficulty because of her extraordinary "delicacy," suffering from a variety of illnesses which somehow always seemed to puzzle the doctors, though some of the symptoms—the vomiting, for example, and the high temperature—were very severe and persistent. Nor does it tell us if later in life, but before the suffering from the pea arose, she had been taken to consult two famous doctors, one of whom had removed the vermiform appendix, while the other a little later had performed an operation for "adhesions." At any rate, the story with these later additions, which are at least in keeping with what we know of her history, would serve to indicate the importance which attaches to the early training of childhood. Among the children even of the well-to-do often enough the hygiene of the mind is overlooked, and faulty management produces restlessness, instability, and hyper-sensitiveness, which pass insensibly into neuropathy in adult life.

To prevent so distressing a result is our aim in the training of children. No doubt the matter concerns in the first place parents and nurses, school masters and mistresses, as well as medical men. Yet because of the certainty that physical disturbances of one sort or another will follow upon nervous unrest, it will seldom happen that medical advice will not be sought sooner or later; and if the physician is to intervene with success, he must be prepared with knowledge of many sorts. He must be prepared to make a thorough and complete physical examination, sufficient to exclude the presence of organic disease. If no organic disease is found, he must explore the whole environment of the child, and seek to determine whether the exciting cause is to be found in the reaction of the child to some form of faulty management.

For example, a child of two or three years of age may be brought to the doctor with the complaint that defaecation is painful, and that there has existed for some time a most distressing constipation which has resisted a large number of purgatives of increasing strength. Whenever the child is placed upon the stool, his crying at once begins, and no attempts to soothe or console him have been successful. It is not sufficient for the doctor in such a case to make an examination which convinces him that there is no fissure at the anus and no fistula or thrombosed pile, and to confine himself to saying that he can find nothing the matter. The crying and refusal to go to stool will continue after the visit as before, and the mother will be apt to conclude that her doctor, though she has the greatest confidence in him for the ailments of grown-up persons, is unskilled in, or at least not interested in, the diseases of little children. If, on the other hand, the doctor pursues his inquiries into the management of the child in the home, and if, for example, he finds that the crying and resistance is not confined to going to stool, but also takes place when the child is put to bed, and very often at meal-times as well, then it will be safe for him to conclude that all the symptoms are due to the same cause—a sort of "negativism" which is apt to appear in all children who are directed and urged too much, and whose parents are not careful to hide from them the anxiety and distress which their conduct occasions.

If this diagnosis is made, then a full and clear explanation should be given to the mother, or at any rate to such mothers—and fortunately they are in the majority—who are capable of appreciating the point of psychology involved, and of correcting the management of the child so as to overcome the negativism. To attempt treatment by prescribing drugs, or in any other way than by correcting the faulty management, is to court failure. As Charcot has said, in functional disorders it is not so much the prescription which matters as the prescriber.

But the task of the doctor is often one of even greater difficulty. Often enough there will be a combination of organic disturbance with functional trouble. For example, a girl of eighteen years old suffered from a pain in the left arm which has persisted on and off since the olecranon had been fractured when she was two years of age. She was the youngest of a large family, and had never been separated for a day from the care and apprehensions of her mother. The joint was stiff, and there was considerable deformity. The pain always increased when she was tired or unhappy. Again, a girl had some slight cystitis with frequent micturition, and this passed by slow degrees into a purely functional irritability of the bladder, which called for micturition at frequent intervals both by day and night. In such cases treatment must endeavour to control both factors—the local organic disturbance must if possible be removed, and the faults of management corrected.

It is a good physician who can appreciate and estimate accurately the temperament of his patient, and the need for this insight is nowhere greater than in dealing with the disorders of childhood. It can be acquired only by long practice and familiarity with children. In the hospital wards we shall learn much that is essential, but we shall not learn this. The child, who is so sensitive to his environment, shows but little that is characteristic when admitted to an institution. Only in the nursery can we learn to estimate the influences which proceed from parents and nurses of different characters and temperaments, and the reaction which is produced by them in the child.

The body of the child is moulded and shaped by the environment in which it grows. Pure air, a rational diet, free movement, give strength and symmetry to every part. Faults of hygiene debase the type, although the type is determined by heredity which in the individual is beyond our control. Mothers and nurses to-day are well aware of the need for a rational hygiene. Mother-craft is studied zealously and with success, and there is no lack of books to give sound guidance and to show the mean between the dangerous extremes of coddling and a too Spartan exposure. Yet sometimes it has seemed as if some mothers whose care for their children's physical health is most painstaking, who have nothing to learn on the question of diet, of exercise, of fresh air, or of baths, who measure and weigh and record with great minuteness, have had their attention so wholly occupied with the care of the body that they do not appreciate the simultaneous growth of the mind, or inquire after its welfare. Yet it is the astounding rapidity with which the mental processes develop that forms the distinguishing characteristic of the infancy of man. Were it not for this rapid growth of the cerebral functions, the rearing of children would be a matter almost as simple and uneventful as the rearing of live stock. For most animals faults of environment must be very pronounced to do harm by producing mental unrest and irritability. Thus, indeed, some wild animal separated from its fellows and kept in solitary captivity may sicken and waste, though maintained and fed with every care. Yet if the whole conditions of life for the animal are not profoundly altered, if the environment is natural or approximately natural, it is as a rule necessary to care only for its physical needs, and we need not fear that the results will be spoiled by the reaction of the mind upon the body. But with the child it is different; airy nurseries, big gardens, visits to the seaside, and every advantage that money can buy cannot achieve success if the child's mind is not at rest, if his sleep is broken, if food is habitually refused or vomited, or if to leave him alone in the nursery for a moment is to evoke a fit of passionate crying.

The grown-up person comes eventually to be able to control this tremendous organ, this brain, which is the predominant feature of his race. In the child its functions are always unstable and liable to be upset. Evidence of mental unrest or fatigue, which is only rarely met with in grown persons and which then betokens serious disturbance of the mind, is of comparatively common occurrence in little children. Habit spasm, bed-wetting, sleep-walking, night terrors, and convulsions are symptoms which are frequent enough in children, and there is no need to be unduly alarmed at their occurrence. In adult age they are found only among persons who must be considered as neuropathic. To make the point clear, I have chosen examples from the graver and more serious symptoms of nervous unrest. But it is equally true that minor symptoms which in adults are universally recognised to be dependent upon cerebral unrest or fatigue are of everyday occurrence in childhood. Broken and disturbed sleep, absence of appetite and persistent refusal of food, gastric pain and discomfort after meals, nervous vomiting, morbid flushing and blushing, headache, irritability and excessive emotional display, at whatever age they occur, are indications of a mind that is not at rest. In children, as in adults, they may be prominent although the physical surroundings of the patient may be all that could be desired and all that wealth can procure. It is an everyday experience that business worries and responsibilities in men, domestic anxieties or childlessness in women, have the power to ruin health, even in those who habitually or grossly break none of its laws. The unstable mind of the child is so sensitive that cerebral fatigue and irritability are produced by causes which seem to us extraordinarily trivial. In the little life which the child leads, a life in which the whole seems to us to be comprised in dressing and undressing, washing, walking, eating, sleeping, and playing, it is not easy to detect where the elements of nervous overstrain lie. Nor is it as a rule in these things that the mischief is to be found. It is in the personality of mother or nurse, in her conduct to the child, in her actions and words, in the tone of her voice when she addresses him, even in the thoughts which pass through her mind and which show themselves plainly to that marvellously acute intuition of his, which divines what she has not spoken, that we must seek for the disturbing element. The mental environment of the child is created by the mother or the nurse. That is her responsibility and her opportunity. The conduct of the child must be the criterion of her success. If things go wrong, if there is constant crying or ungovernable temper, if sleep and food are persistently refused, or if there is undue timidity and tearfulness, there is danger that seeds may be sown from which nervous disorders will spring in the future.

There are many women who, without any deep thought on the matter, have the inborn knack of managing children, who seem to understand them, and have a feeling for them. With them, we say, the children are always good, and they are good because the element of nervous overstrain has not arisen. There are other women, often very fond of children, who are conspicuously lacking in this power. Contact with one of these well-meaning persons, even for a few days, will demoralise a whole nursery. Tempers grow wild and unruly, sleep disappears, fretfulness and irritability take its place. Yet of most mothers it is probably true that they are neither strikingly proficient nor utterly deficient in the power of managing children. If they lack the gift that comes naturally to some women, they learn from experience and grow instinctively to feel when they have made a false step with the child. Although by dearly bought experience they learn wisdom in the management of their children, they nevertheless may not study the subject with the same care which they devote to matters of diet and hygiene. It is the mother whose education and understanding best fits her for this task. In this country a separate nursery and a separate nursery life for the children is found in nearly all households among the well-to-do, and the care for the physical needs of the children is largely taken off the mothers' shoulders by nurses and nursemaids. That this arrangement is advantageous on the whole cannot be doubted. In America and on the Continent, where the children often mingle all day in the general life of the household, and occupy the ordinary living rooms, experience shows that nerve strain and its attendant evils are more common than with us. Nevertheless, the arrangement of a separate nursery has its disadvantages. Nurses are sometimes not sufficiently educated to have much appreciation of the mental processes of the child. If the children are restless and nervous they are content to attribute this to naughtiness or to constipation, or to some other physical ailment. Their time is usually so fully occupied that they cannot be expected to be very zealous in reading books on the management of children. Nevertheless, in practical matters of detail a good nurse will learn rapidly from a mother who has given some attention to the subject, and who is able to give explicit instructions upon definite points.

It is right that mothers should appreciate the important part which the environment plays in all the mental processes of children, and in their physical condition as well; that they should understand that good temper and happiness mean a proper environment, and that constant crying and fretfulness, broken sleep, refusal of food, vomiting, undue thinness, and extreme timidity often indicate that something in this direction is at fault.

Nevertheless, we must be careful not to overstate our case. We must remember how great is the diversity of temperament in children—a diversity which is produced purely by hereditary factors. The task of all mothers is by no means of equal difficulty. There are children in whom quite gross faults in training produce but little permanent damage; there are others of so sensitive a nervous organisation that their environment requires the most delicate adjustment, and when matters have gone wrong, it may be very difficult to restore health of mind and body. When a peculiarly nervous temperament is inherited, wisdom in the management of the child is essential, and may sometimes achieve the happiest results. Heredity is so powerful a factor in the development of the nervous organisation of the child that, realising its importance, we should be sparing in our criticism of the results which the mothers who consult us achieve in the training of their children. A sensitive, nervous organisation is often the mark of intellectual possibilities above the average, and the children who are cast outside the ordinary mould, who are the most wayward, the most intractable, who react to trifling faults of management with the most striking symptoms of disturbance, are often those with the greatest potentialities for achievement and for good. It is natural for the mother of placid, contented, and perhaps rather unenterprising children, looking on as a detached outsider, seeing nothing of the teeming activities of the quick, restless little brain, and the persistent, though faulty reasoning—it is natural for her to blame another's work, and to flatter herself that her own routine would have avoided all these troublesome complications. The mother of the nervous child may often rightly take comfort in the thought that her child is worth the extra trouble and the extra care which he demands, because he is sent into the world with mechanism which, just because it is more powerful than the common run, is more difficult to master and takes longer to control and to apply for useful ends.

It is through the mother, and by means of her alone, that the doctor can influence the conduct of the child. Without her co-operation, or if she fails to appreciate the whole situation, with the best will in the world, we are powerless to help. Fortunately with the majority of educated mothers there is no difficulty. Their powers of observation in all matters concerning their children are usually very great. It is their interpretation of what they have observed that is often faulty. Thus, in the example given above, the mother observes correctly that defaecation is inhibited, and produces crying and resistance. It is her interpretation that the cause is to be found in pain that is at fault. Again, a mother may bring her infant for tongue-tie. She has observed correctly that the child is unable to sustain the suction necessary for efficient lactation, and has hit upon this fanciful and traditional explanation. The doctor, who knows that the tongue takes no part in the act of sucking, will probably be able to demonstrate that the failure to suck is due to nasal obstruction, and that the child is forced to let go the nipple because respiration is impeded. The opportunities for close observation of the child which mothers enjoy are so great that we shall not often be justified in disregarding their statements. But if we are able to give the true explanation of the symptoms, it will seldom happen that the mother will fail to be convinced, because the explanation, if true, will fit accurately with all that has been observed. Thus the mother of the child in whom defaecation is inhibited by negativism may have made further observations. For example, she may have noted that the so-called constipation causes fretfulness, that it is almost always benefited by a visit to the country or seaside, or that it has become much worse since a new nurse, who is much distressed by it, has taken over the management of the child. To this mother the explanation must be extended to fit these observations, of the accuracy of which there need be no doubt. Fretfulness and negativism with all children whose management is at fault come in waves and cycles. The child, naughty and almost unmanageable one week, may behave as a model of propriety the next. The negativism and refusal to go to stool are the outcome of the nervous unrest, not its cause. Again, the nervous child, like the adult neuropath, very often improves for the time being with every change of scene and surroundings. It is the ennui and monotony of daily existence, in contact with the same restricted circle, that becomes insupportable and brings into prominence the lack of moral discipline, the fretfulness, and spirit of opposition. Lastly, the conduct of the nervous child is determined to a great extent by suggestions derived from the grown-up people around him. Refusal of food, refusal of sleep, refusal to go to stool, as we shall see later, only become frequent or habitual when the child's conduct visibly distresses the nurse or mother, and when the child fully appreciates the stir which he is creating. The mother will readily understand that in such a case, where constipation varies in degree according as different persons take charge of the child, the explanation offered is that which alone fits with the observed facts. A full and free discussion between mother and doctor, repeated it may be more than once, may be necessary before the truth is arrived at, and a line of action decided upon. Only so can the doctor, remote as he is from the environment of the child, intervene to mould its nature and shape its conduct.

If the doctor is to fit himself to give advice of this sort, he must be a close observer of little children. He must not consider it beneath his dignity to study nursery life and nursery ways. There he will find the very beginnings of things, the growing point, as it were, of all neuropathy. A man of fifty, who in many other ways showed evidence of a highly nervous temperament, had especially one well-marked phobia, the fear of falling downstairs. It had never been absent all his life, and he had grown used to making the descent of the stairs clinging firmly to the stair-rail. Family tradition assigned this infirmity to a fall downstairs in early childhood. But all children fall downstairs and are none the worse. The persistence of the fear was due, I make no doubt, to the attitude of the parents or nurse, who made much of the accident, impressed the occasion strongly on the child's memory, and surrounded him thereafter with precautions which sapped his confidence and fanned his fears.

In what follows we will consider first the subject of nursery management, searching in it for the origin of the common disorders of conduct both of childhood and of later life. I have grouped these nursery observations under the heads of four characteristic features of the child's psychology—his Imitativeness, his Suggestibility, his Love of Power, and his acute though limited Reasoning Faculties. I feel that some such brief examination is necessary if we are to understand correctly the aetiology of some of the most troublesome disorders of childhood, such as enuresis, anorexia, dyspepsia, or constipation, disorders in which the nervous element is perhaps to-day not sufficiently emphasised. Finally, we can evolve a kind of nursery psycho-therapeutics—a subject which is not only of fascinating interest in itself, but which repays consideration by the success which it brings to our efforts to cure and control.



CHAPTER II

OBSERVATIONS IN THE NURSERY

(a) THE IMITATIVENESS OF THE CHILD

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

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

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

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

[Footnote 1: The Montessori Method, pp. 84, 85.]

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

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

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

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

(b) THE SUGGESTIBILITY OF THE CHILD

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

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

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

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

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

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

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

(c) THE CHILD'S LOVE OF POWER

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

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

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

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

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

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

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

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

(d) THE REASONING POWER OF THE CHILD

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

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

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

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

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

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

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

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

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

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

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



CHAPTER III

WANT OF APPETITE AND INDIGESTION

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

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

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

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

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

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

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

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

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