The Nervous Child

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

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

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

Migraine and Cyclic Vomiting

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

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

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

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

Unexplained Pyrexia

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

CHAPTER VI

ENURESIS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHAPTER VII

TOYS, BOOKS, AND AMUSEMENTS

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

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

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

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

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

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

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

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

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

CHAPTER VIII

NERVOUSNESS IN EARLY INFANCY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHAPTER IX

MANAGEMENT IN LATER CHILDHOOD

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

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