The Nervous Child

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

Physical Training

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

Mental Training

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

Moral Training

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

And so with children! Parents must take it for granted that they will display all the virtues they desire in them. They must trust to their honour always to speak the truth, and always to do their best in work or play whether they are with them or not. Again and again the children will fail and their patience will be tried to the utmost. They must explain how serious is the fault, and for the time being their trust may have to be removed; but with the promise of amendment it must again be fully restored and the lapse completely forgotten. If the child feels he is not trusted he ceases to make any effort, and lapse will succeed lapse with increasing frequency.

In efforts at moral training there is often too great an emphasis laid upon negative virtues. It is wrong to do this: to do that is forbidden. Children cannot progress by merely avoiding faults any more than a man may claim to be an agreeable companion at table because he does not eat peas with a knife or drink with his mouth full. There must be a constant effort to achieve some positive good, to acquire knowledge, to do service, to take thought for others, to discipline self, and the parent will get the best result who is comparatively blind to failure but quick to encourage effort and to appreciate success. When the child knows well that he is doing wrong, exhortation and expostulation are usually of little avail if repeated too often, and serious talks should only take place at long intervals.

We know how effective the so-called "therapeutic conversation" may be in helping some overwrought and nervously exhausted man or woman to regain peace of mind and self-control. After an intimate conversation with a medical man who knows how to draw from the patient a free expression of the doubts, anxieties, and fears which are obsessing him, many a patient feels as though he had awakened in that instant from a nightmare, and passes from the consulting-room to find his troubles become of little account. Not a few patients return to be reassured once more, and derive new strength on each occasion. Yet visits such as these must be infrequent or they will lose their power. Now, just as the physician is well aware that his intervention if too frequently repeated will lose its effect, so the parent must be chary of too frequent an appeal to the moral sense of the child. At long intervals opportunity may be taken with all seriousness to set before the child ideals of conduct, to-speak to him of the meaning of character and of self-discipline, and of the standards by which we judge a man or woman to be weak and despicable, or strong and to be admired. The effect of such an intimate conversation, never repeated, may persist throughout life. Constantly reiterated appeals, on the other hand, do more harm than good. To tell a child daily that he is "breaking mother's heart," or that he is "disappointing his father," is to debase the moral appeal and deprive it of its strength.

For everyday use it is best to cultivate a manner which can indicate to the child that he is for the moment unpopular, but which at the same time denies to the small sinner the interest of attempting his own defence. On the other hand, should the child be reasonably in doubt as to the nature of his offence we must spare no trouble in explaining it to him. Punishment will be most effective when the child is convinced that he is rightly convicted. If it is to act as a real deterrent, he must agree to be punished—a frame of mind which, if it can be produced, may be welcomed as a sure sign that training is proceeding along the right lines.

By physical training, mental training, and moral training the child's character is formed and self-discipline is developed. With the child of neuropathic disposition and inheritance matters may not proceed so smoothly. Reasoning and conduct may be alike faulty, and the nervous disturbances may even cause detriment to the physical health. Not that the nervous child requires an environment different from that of the normal child. The difficulties which the parents will encounter and the problems which must be solved differ not in kind but in degree. An error of environment which is without effect in the normal child may be sufficient to produce disastrous results in the neuropathic.

It must be granted that there are some unfortunate children in whom the moral sense remains absent and cannot be developed—children who steal and lie, who seem destitute of natural affection, or who appear to delight in acts of cruelty. These moral degenerates need not be considered here. Serious errors of conduct, however, in children who are not degenerate or imbecile, frequently arise directly from faults of management and can be controlled by correcting these faults. Suppose, for example, that a child is found to have taken money not his own. The action of the parents faced with this difficulty and disappointment will determine to a great extent whether the incident is productive of permanent damage to the child's character. The peculiar circumstances of each case must be considered. For example, the parent must bear in mind the relation in which children stand to all property. The child possesses nothing of his own; everything belongs in reality to his father and mother, but of all things necessary for him he has the free and unquestioned use. Unless his attention has been specially directed to the conception of ownership and the nature of theft, he may not have reasoned very closely on the matter at all. Very probably he knows that it is wrong to take what is not given him, but he does not regard helping himself to some dainty from a cupboard as more than an act of disobedience to authority. He may have imbibed no ideas which place the abstraction of money from a purse belonging to his parents on a different plane, and which have taught him to regard such an action as especially dishonourable and criminal. Finally, a child who, undetected, has more than once taken money belonging to his father and mother, may pass without much thought to steal from a visitor or a servant. To deal with such a case effectively, to ensure that it shall never happen again, requires much insight. If the father, shocked beyond measure to find his son an incipient criminal, differing in his guilt in no way from boys who are sent to reformatories as bad characters, convinces the child that although he did not realise it, he has shown himself unworthy of any further trust, untold harm will be done. Almost certainly the child will act in the future according to the suggestions which are thus implanted in his mind. If the household eyes him askance as a thief, if confidence is withdrawn from him, he sees himself as others see him and will react to the suggestions by repeating the offence. The seriousness of what he has done should be explained to him, and after due punishment he must be restored completely and ostentatiously to absolute trust. Only by showing confidence in him can we hope to do away with the dangers of the whole incident. To inculcate good habits and encourage good behaviour we must let the child build up his own reputation for these virtues. It need not make him priggish or self-satisfied if parents let him understand that they take pride in seeing him practise and develop the virtue they aim at. For example, it is desired above all that he should always speak the truth. Then they must ostentatiously attach to him the reputation of truthfulness and show their pride in his possessing it. If he falls from grace they must remember that he is still a child, and that if that reputation is lightly taken from him and he is accused of a permanent tendency towards untruthfulness, he is left hopeless and resigned to evil. Let any mother make the experiment of presenting to her child in this way a reputation for some particular virtue. For example, if an older child shows too great a tendency to tease and interfere with the younger children, let the mother seize the first opportunity which presents itself to applaud some action in which he has shown consideration for the others. Let her comment more than once in the next few days on how careful and gentle the older child is becoming in his behaviour to the little ones, and in a little the suggestion will begin to act until the transformation is complete. If, on the other hand, the mother adopts the opposite course and rebukes the child for habitual unkindness, she will be apt to find unkindness persisted in. The criminal records of the nation show too often the truth of the saying that "Once a thief always a thief." Deprived of his good repute, man loses his chief protection against evil and his incentive to good.

The inability of a child—and especially of a nervous and sensitive child—to form conceptions of his own individuality except from ideas derived from the suggestions of others, gives us the key to our management of him and to our control of his conduct. He has, as a rule, a marvellously quick perception of our own estimate of him, and unconsciously is influenced by it in his conception of his own personality, and in all his actions. Parents must believe in his inherent virtue in spite of all lapses. If they despair it cannot be hid from the child. He knows it intuitively and despairs also. It is then that they call him incorrigible. If it happens that one parent becomes estranged from the child, despairs of all improvement, and sees in all his conduct the natural result of an inborn disposition to evil, while the other parent holds to the opinion that the child's nature is good, and to the belief that all will come right, then often enough the child's conduct shows the effect of these opposite influences. In contact with the first he steadily deteriorates, affording proof after proof that judgment against him has been rightly pronounced. In contact with the other, though his character and conduct are bound to suffer from such an unhappy experience, he yet shows the best side of his nature and keeps alive the conviction that he is not all bad.

The force of suggestion is still powerful to control conduct and determine character in later childhood. The impetus given by the parents in this way is only gradually replaced by the driving power of his own self-respect—a self-respect based upon self-analysis in the light of the greater experience he has acquired.

CHAPTER X

NERVOUSNESS IN OLDER CHILDREN

In older children the line which separates naughtiness, fractiousness, and restlessness from definite neuropathy begins to be more marked. The nature of the young child, taking its colour from its surroundings, is sensitive, mobile, and inconstant. With every year that passes, the normal child loses something of this impressionable and fluid quality. With increasing experience and with a growing power to argue from ascertained facts, character becomes formed, and if tempered by discipline will come to present a more and more unyielding surface to environment, until finally it becomes set into the stability of adult age.

We may perhaps, with some approach to truth, look upon the adult neurotic as one whose character retains something of the impressionable quality of childhood throughout life, so that, to the last, environment influences conduct more than is natural.

All the emotions of neurotic persons are exaggerated. Disappointments over trifles cause serious upsets; grief becomes overmastering. Violent and perhaps ill-conceived affection for individuals is apt to be followed by bitter dislike and angry quarrelling. On the physical side, sense perception is abnormally acute, and many sensations which do not usually rise up into consciousness at all become a source of almost intolerable suffering. To these most unhappy people summer is too hot and winter too cold; fresh air is an uncomfortable draught, while too close an atmosphere produces symptoms of impending suffocation.

In some neurotics there is an excessive interest in all the processes of the life of the body, and when attention is once attracted to that which usually proceeds unconsciously, symptoms of discomfort are apt to arise. Thus so simple an act as swallowing may become difficult, or for the time being impossible. To breathe properly and without a sense of suffocation may seem to require the sustained attention of the patient; or again, the voice may be suddenly lost.

More commonly, perhaps, neuropathy exhibits itself in an undue tendency to show signs of fatigue upon exertion of any sort, mental or physical. Sustained interest in any pursuit or task becomes impossible. Nameless fears and unaccountable sensations of dread establish themselves suddenly and without warning, and may be accompanied on the physical side by palpitation, flushing, headache, or acute digestive disturbances.

All these manifestations are best controlled by selecting a suitable environment, and as a rule the character of the environment is determined by the temperament and disposition of those who live in close contact with the patient. Like the tiny children with whom we have dealt so far, the behaviour of neuropathic persons is subject wholly to the direction of stronger and more dominant natures. With faulty management at the hands of those around them, no matter how loving and patient these may be, the conduct of the neurotic tends to become abnormal.

In children beyond earliest infancy we recognise a gradual approach to the conditions of adult life. Fractiousness and naughtiness, ungovernable fits of temper, inconsolable weeping and inexplicable fears should disappear with early childhood even if management has not been perfect. If they persist to older childhood we shall find in an increasing percentage of cases evidence of definite neuropathic tendencies which urgently call for investigation and for a precise appreciation of the nature of the abnormality. It may be that the only effective treatment is that which we recognise as essential in the grosser mental disturbances—removal from the surroundings in which the abnormal conduct has had free play, and separation from the relatives whose anxiety and alarm cannot be hidden.

In young nervous children fear is the most prominent psychical symptom. The children are afraid of everything strange with which they come in contact. They are afraid of animals, of a strange face, or an unfamiliar room. Older children usually manage to control themselves, suppress their tears, and prevent themselves from crying out, but it is nevertheless easy to detect the struggle.

Often we find those distressing attacks to which the name "night-terrors" has been given. The child wakes with a cry,—usually soon after he has gone to sleep,—sits up in bed and shows signs of extreme terror, gazing at some object of his dreams with wide-open startled eyes, begging his nurse or mother to keep off the black dog, or the man, or whatever the vision may be. Even after the light is turned up and the child has been comforted, the terror continues, and half an hour may elapse before he becomes quiet and can be persuaded to go back to bed. In the morning as a rule he remembers nothing at all.

Phobias of all sorts are common in nervous children, and result from a morbid exaggeration of the instinct for self-preservation. Some cannot bear to look from a height, others grow confused and frightened in a crowd; dread of travelling, of being in an enclosed space such as a church or a schoolroom, or of handling sharp objects may develop into a constant obsession. I have known a little girl who was seized with violent fear whenever her father or mother was absent from the house, and she would stand for hours at the window in an agony of terror lest some harm should have befallen them. As if with some strange notion of propitiating the powers of darkness these children will often constantly perform some action and will refuse to be happy until they have done so. The same little girl who suffered such torments of anxiety in her parents' absence would always refuse to go to bed unless she had stood in turn on all the doormats on the staircase of her home. Other children feel themselves forced to utter certain words or to go through certain rhythmical movements. They fully understand that the fear in their mind is irrational and devoid of foundation, but they are unable to expel it. Often it is hugged as a jealous secret, so that the childish suffering is only revealed to others years afterwards, when adult age has brought freedom from it. We will do well to try by skilful questioning to gain an insight into the mental processes of a child when we find him showing an uncontrollable desire to touch lamp-posts or to stand in certain positions; or when he develops an excessive fear of getting dirty, or is constantly washing his hands to purify them from some fancied contamination.

The treatment of all these symptoms calls for much insight. The child's confidence must be completely secured, and he must be encouraged to tell of all his sensations and of the reasons which prompt his actions. The nervous child has a horror of appearing unlike other children, and will suffer in silence. If his troubles are brought into the light of day with kindness and sympathy they will melt before his eyes. Even night-terrors are, as a rule, determined by the suppressed fears of his waking hours. If they are provoked by his experiences at school, by the fear of punishment or by dismay at a task that has proved beyond his powers, he should be taken away from school for the time being. Night-terrors are said to be aggravated by nasal obstruction due to adenoid vegetations. Clothing at night should be light and porous, and particular attention should be paid to the need for free ventilation.

We have spoken in an earlier chapter of the trouble sometimes experienced in inducing a nervous child to go to sleep. In older children insomnia is common enough. Even when sleep comes it may be light and broken, as though the child slept just below the surface of consciousness and did not descend into the depths of sound and tranquil slumber. We have often noticed how different is the estimate of the patient from that of the nurse as to the number of hours of sleep during the night. The sick man maintains that he has hardly slept at all, whilst the nurse, drawing us aside, whispers in our ear that he has slept most of the night. In estimating sleep we have to consider not only its duration, but also its depth, and the patient who denies that he has slept at all has lain perhaps half the night with an active restless brain betwixt sleep and wakefulness. Often enough when he comes to consider in the morning the problems that vexed his soul at midnight, he is quite unable to recall their nature, and recognises them as the airy stuff that dreams are made of. Although in a sense asleep he may have retained a half-consciousness of his surroundings and a sense of despair at the continued absence of a sounder sleep.

With nervous children we are apt to find sleep which is of little depth and which constantly shows evidence of a too-active brain. The body is tossed to and fro, words are muttered, and the respiration is hurried and with a change in rhythm, because there is no depth of anæsthesia. The body still responds to the impulses of the too-active brain. From the nature of his dream—as shown by chance words overheard—we may sometimes gather hints to help us to find where the elements of unrest in his daily life lie. Sleep-walking is only a further stage in this same disorder of sleep, in which the dream has become so vivid that it is translated into motor action.

If a child begins to suffer from active sleeplessness we must not make the mistake of urging him to sleep. He is no more capable than we are ourselves of achieving sleep by an effort of will power. To urge him to sleep is likely to cause him to keep awake because we direct his attention to the difficulty and make him fear that sleep will not come. If he understands that all that he needs is rest, he will probably fall asleep without further trouble.

Day-dreams also may become abnormal, and tell of an unduly nervous temperament. Any one who watches a little child at play will realise the strength of his power of imagination. The story of Red Riding Hood told by the nursery fire excites in the mind of the child an unquestioning belief which is never granted in later life to the most elaborate efforts of the theatre. All this imaginative force is natural for the child. It becomes abnormal only when things seen and acts performed in imagination are so vivid as to produce the impression of actual occurrences, and when the child is so under the sway of his day-dreams that he fails to realise the difference between pretence and reality. Imagination which keeps in touch with reality by means of books and dolls and toys is natural enough. Not so imagination which leads to communion with unseen familiars or to acts of violence due to the organisation of "conspiracies" or "robber bands" amongst schoolboys.

If evidence of abnormal imagination appears, the child must be kept in close touch with reality. We must give him interesting and rational occupation, such as drawing, painting, the making of collections of all sorts, gardening, manual work, and so forth. In older children we must especially supervise the reading.

In many nervous children we find a faulty contact with environment, so that instead of becoming interested in the thousand-and-one happenings of everyday life and experiences, they become introspective and self-conscious. As a result, sensations of all sorts, which are commonly insufficient to arouse the conscious mind, attract attention and, rising into consciousness, occupy the interest to the exclusion of everything else. The conscious mind is not capable of being occupied by more than one thing at a time. If attention is concentrated upon external matters, bodily sensations, even extreme pain, may pass altogether unnoticed. The Mohawk, Lord Macaulay tells us, hardly feels the scalping-knife as he shouts his death song. The soldier in the excitement of battle is often bereft of all sense of pain. On the other hand, the patient who is morbidly self-conscious becomes oblivious of his surroundings while he suffers intensely from sensations which are usually not appreciated at all. Self-conscious children will complain much of breathlessness and a sense of suffocation, of headache, of palpitation, of intolerable itching, of the pressure of clothing, or of flushing and a sense of heat. Excessive introspection influences their conduct in many ways. At children's parties, for example, they will be found wandering about unhappy, dazed and unable to feel the reality of the surroundings which afford such joy to the others; or they may be anxious to join in play, but finding themselves called upon to take their turn are apt to stand helplessly inactive, or to burst into tears. At school, though they may be really quick to learn, they will often be found oblivious of all that has gone on around them, not from stupidity, but from inability to dissociate their thoughts from themselves and to concentrate attention upon the matter in hand. In such a case we must aim at developing the child's interest to the exclusion of this morbid introspection. Taking advantage of his individual aptitude, we must strengthen his hold upon externals in every way possible, and we must explain to him the nature of his failing and teach him that his salvation lies in cultivating his capacity for paying attention to things around him and developing an interest in suitable occupations.

Fainting fits are not uncommon amongst nervous children from about the sixth year onwards, and are apt to give rise to an unwarranted suspicion of epilepsy. In other cases fears have been aroused that the heart may be diseased. In children who faint habitually the nervous control of the circulation is deficient. We notice that when they are tired by play, or when they are suffering from the reaction that follows excitement of any sort, the face is apt to become pale, and dark lines may appear under the eyes. Yet there may be no true anæmia present: it is only that the skin is poorly supplied with blood for the moment. After a little rest in bed, or under the influence of a new excitement, the colour returns, and the tired look vanishes. If children of this type are made to stand motionless for any length of time, and if at the same time there is nothing to attract their interest or attention—a combination of circumstances which unhappily is sometimes to be found during early morning prayers at school—the want of tone in the blood vessels may leave the brain so anaemic that fainting follows. The first fainting attack is a considerable misfortune, because the fear of a recurrence is a potent cause of a repetition. Standing upright with the body at rest and the mind vacant, the circulation stagnates, the boy's mind is attracted by the suggestion, he fears that he will faint as he has done before, and he faints. Schoolmasters are well aware that if one or two boys faint in chapel and are carried out, the trouble may grow to the proportion of a veritable epidemic. It is important that this habit of fainting should be combated not only by general means to improve the tone of the body and circulation, but also by taking care that the child understands the nature of the fainting fit, and the part which association of ideas plays in producing it. Disease of the heart seldom gives rise to fainting.

The same vasomotor instability which shows itself in the tendency to syncopal attacks is apparent in many other ways. Sudden sensations of heat and of flushing, equally sudden attacks of pallor, coldness of the extremities, abundant perspiration,—raising in the mind of the anxious mother the fear of consumption,—and excessive diuresis are common accompaniments. A further group of symptoms is provided by the extreme sensibility of the digestive apparatus. Dyspepsia, hyperaesthesia of the intestinal tract, viscero-motor atonies and spasms, and anomalies of the secretions, whether specific like that of the gastric juice or indifferent like that of the nasal, pharyngeal, gastric, and intestinal mucus, are all of common occurrence. Whenever the nervous child is subjected to any exhausting experience, any excitement, pleasurable or the reverse, or any undue exertion, whether mental or physical, one may note the subsequent gastro-intestinal derangement, including even a coating of the tongue. The slightest deviation from the usual diet, the most trivial fatigue, a chill of the body, even a change in the temperature of the food may set loose the most extreme reactions in the gastro-intestinal tract—motor, sensory, or secretory. It is not an accident that so often the mucous diarrhoea, which may have afflicted an excitable child in London for many months, and which a visit to the seaside, with all its healthy activities, may seem to have completely cured, relapses within a day or two of the return to the restricted environment and uninteresting routine of life in London. The child who was happy and busy and at peace with himself, at play in the open air, resents the sudden cessation of all this, and the nervous unrest returns. To attempt treatment by dietetic restrictions alone is to deal only with a symptom. The gastro-intestinal reactions are so violent that the parents are generally voluble on the subject of the many foods which cannot be taken and the few which are not suspect. To prescribe rigid tables of diet is to add to the alarm of the mother, and to sustain her in the belief that the child is in daily danger of being poisoned by a variety of common articles of diet. Only by lowering the excitability of the nervous system, by occupying the mind and giving strength to the child's powers of control can we effectively combat the hyperaesthesia. If necessary the personnel of the management of the child will have to be altered. There may be no other way to achieve certain and rapid improvement in a condition which is causing grave danger to the child and very genuine distress and suffering to the parents. A violent reaction to intoxications of all sorts is a further stigma of nervous instability. Sudden and even inexplicable rises of temperature are frequent complaints, and the constitutional effects of even trivial local infections are apt to be disproportionately great.

Fatigue is easily induced and is exhibited in all varieties of activity—mental, physical, or visceral. Mental work may produce fatigue with extreme readiness even although the quality of the work may remain of a high standard. To Darwin and to Zola work for more than three hours daily was an impossibility, and yet their work done under these restrictions excites all men's admiration. The palpitation and breathlessness which follows upon trivial exertion, such as climbing a flight of stairs, is a good example of visceral fatigue.

Among adult neuropaths we recognise the harm which may be done by unwise speeches on the part of relatives, or still more on the part of doctors. A chance word from a doctor or nurse off their guard for the moment will implant in the minds of many such a person the unyielding conviction that he or she is suffering from some gastric complaint, from some cardiac affection, or from some constriction of the bowel. It may take the united force of many doctors to uproot this pathological doubt which was implanted so easily and so carelessly. The medical student is notoriously prone to recognise in himself the symptoms of ailments which he hears discussed. Little children, too, are apt to suffer in the same way. How much illness could be avoided if mothers would cease to erect some single manifestation of insufficient nervous control into a local disorder which becomes an object of anxiety to the child and to the whole household.

Undue liability to fatigue, irritability, instability, lack of control over the emotions, extreme suggestibility, prompt and exaggerated reactions to toxins of all sorts, excessive vasomotor reactions and anomalies of secretion, weakness of the gastro-intestinal apparatus—these, and many other symptoms, are of everyday occurrence in the nervous child. To discuss them more fully would be to pass too far from our nursery studies into a consideration of psychological medicine.

CHAPTER XI

NERVOUSNESS AND PHYSIQUE

It has already been said that symptoms of nervousness are often accompanied by faults in the physical development of the child. The defects may assume so many forms as to make any attempt at description very difficult. Nevertheless, certain types of physical defect present themselves with sufficient frequency, in combination with neurosis, to merit a detailed description. For example, we recognise a type of nervous child which is marked by a persistence into later childhood of certain infantile characteristics of the build and shape of body. Further, we meet with a group characterised by a special want of tone in the skeletal muscles, by lordosis, by postural albuminuria, and by abdominal and intestinal disturbances of various sorts. We recognise also the rheumatic type of child with a tendency to chorea, and in contrast to this a type with listlessness, immobility, and katatonia. Lastly, in a few children, in boys as well as in girls, we may meet with cases of hysteria.[3]

(1) A Group with Persistence of Certain Infantile Characteristics

During the first year or eighteen months of life, the rounded infantile shape of body persists. The limbs are short and thick, the cheeks full and rounded, the thorax and pelvis are small, the abdomen relatively large and full. The great adipose deposit in the subcutaneous tissue serves as a depôt in which water is stored in large amounts. In the healthy child of normal development by the end of the second year a great change has taken place. The shape of the body has become more like that of an adult in miniature. The limbs have grown longer and slimmer. The thorax and pelvis have developed so as to produce relatively a diminution in the size of the abdomen. The body fat is still considerable, but no longer completely obliterates the bony prominences of the skeleton. Delay in this change, in this putting aside of the infantile habit of body, is commonly associated with a corresponding backwardness in the mental development. Such children walk late, talk late, learn late to feed themselves, to bite, and to chew effectively. Watery and fat, they carry with them into later childhood the infantile susceptibility to catarrhal infections of the lung, bowel, skin, etc., and they are apt to suffer, in consequence, from a succession of pyrexial attacks. Nasal catarrh, bronchitis, otitis media, enteritis, eczema, urticaria papulata, are apt to follow each other in turn, giving rise in many cases to a persistent enlargement of the corresponding lymphatic glands. The effect upon the different tissues of the body of these repeated infections is very various. We are probably not wrong in attributing the failure to develop and the persistently infantile appearance to a prejudicial effect upon the various ductless glands in the body. The condition is associated with an excessive retention of fluid in the body, secondary in all probability to alterations in the concentration and distribution of the saline constituents of the body. A rapid excretion of salts may be followed by a correspondingly speedy dehydration of the body, a retention of salts by a sudden increase of weight. The parathyroid glands are probably closely concerned in regulating the retention and excretion of salts, and especially of calcium, a circumstance which becomes of significance when we remember how frequently rickety changes, tetany, and other convulsive seizures form part of the clinical picture which we are now considering. While it is difficult to determine the effect of repeated infections upon the functions of the endocrine glands, we have clear evidence of the deleterious influence upon almost all the tissues of the body, the functioning of which it is more easy to estimate. For example, the cells of the skin and of the mucous membranes which happen to be visible to the eye show clear evidence of diminished vitality and increased vulnerability. Physiological stimuli, incapable of producing any visible reaction in healthy children, habitually determine widely spread and persistent inflammatory reactions. For example, the licking movements of the tongue at the corners of the mouth produce the little unhealthy fissures which the French call perlèche. The physiological stimulus of the erupting tooth is capable of causing a painful irritation of the gum, so that the child is said to suffer from teething, accompanied, it may be, and the association is significant, by "teething convulsions." The irritation of the urine produces rawness and excoriation of the skin of the prepuce, contact with intestinal contents not in themselves very abnormal, an intractable dermatitis of the buttocks or a persistent diarrhoea and enteral catarrh. Improvement in the general health, the result of the cessation for the time being of the recurrent infections, perhaps consequent upon improved hygienic conditions, always determines the rapid disappearance of all these accompaniments of the general diminution of tissue vitality.

The muscular system and the bones are commonly also involved, so that rickety changes are often found in these infantile and watery children. In early childhood the processes of calcification and decalcification proceed side by side and with great rapidity, and in health there is always a balance on the side of the constructive process. In the children whom we are now considering, saturated as they are, from time to time, with the toxins resulting from repeated infection, ossification may be so interfered with as to cause softening and bending, with the evolution of a state of rickets. Between bone and muscle, too, we find a close relationship. We do not find powerful muscles with softened bone, nor flabby muscle with rigid and well-formed bone.

In the nervous system, the conditions are somewhat different. In skin, in bone, and in muscle new cell elements are constantly being formed, and the life of the individual cell is relatively short. In the nervous system, on the other hand, the individual cells are long lived. Their life-history may even be coterminous with that of the individual, and if destroyed they are not replaced. Nevertheless, they do not escape undamaged in the general disturbance. In a deprivation of calcium we have, in all probability, the explanation of the increased irritability of peripheral nerves and of the tendency to convulsive seizures of all sorts which is a common accompaniment of the condition. Convulsions, laryngismus stridulus, tetany, or carpopedal spasm are all frequently met with. In crying, the children hold their breath to the point of producing extreme cyanosis, ending, as the spasm relaxes, with a crowing inspiration, which resembles and yet differs in tone from both the whoop of whooping-cough and the crowing inspiration of croup.

Apart, however, from this tendency to convulsive seizures the nervous system of these children is abnormal. As a rule they are excitable, and develop late the power to control their emotions. Lagging behind in physical development and in the capacity to interest themselves in the pursuits of normal children, their emotional state remains that of a much younger child. In the infant classes at schools they are recognised as dullards, learning slowly, speaking badly, and lacking co-ordination in all muscular movements.

The clinical picture so depicted is encountered with extreme frequency among the children of the poor in our large cities. To find a name for the condition is no easy matter. To call it "rickets" is to place an undue emphasis upon the bony changes which, though common, are by no means invariable. Elsewhere I have suggested the name status catarrhalis, on an analogy with the name status lymphaticus, which in the post-mortem room is used to describe the secondary overgrowth of lymphatic tissue which is found in these catarrhal children. In the present connection it is of interest to us to note how commonly the nervous system is involved in the general picture and the frequency both of convulsive disorders and of neuropathy.

The nervous symptoms of both sorts are to be allayed only by improving the general hygiene of the child and raising its resistance against infection. A sufficiency of fresh air and of sunlight, and a management which encourages independence of action in the child, are both necessary. The diet is of the first importance. It should be sufficient, and no more than sufficient, to cover the physiological needs of the child for food. The majority of these children have enormous appetites, and excess of food, and especially of carbohydrate food, plays some part in the production of the disturbance. We must guard against overfeeding, against want of air and want of exercise, and against those errors of management described in previous chapters, which produce the maximum of disturbance in this type of child.

(2) A Group with Muscular Atrophy, Lordosis, and Postural Albuminuria

At an older age, in children from the fifth year onwards, a second type of physical defect associated with pronounced nervous disturbance presents itself with some frequency. The body is thin and badly nourished, and the muscular system especially poorly developed and very lax in tone. The most striking feature is the extreme lordosis, accompanied usually by a secondary and compensatory curve in the cervico-dorsal region, so that the shoulders are rounded, with the head poked forward. Viewed from in front the abdomen is seen to be prominent, overhanging the symphysis pubis, while the shoulders have receded far backwards. The scapulæ have been dragged apart, as though by the weight of the dependent arms, with eversion of their vertebral borders and lowering of the points of the shoulders. The position which they adopt is that into which the body falls when it ceases to be braced by strong muscular support. The muscular system is here so weakly developed and so toneless that the posture is determined by the bony structure and its ligamentous attachments.

The lordosis resembles the similar deformity which develops in cases of primary myopathy, when the spinal muscles have undergone complete atrophy. As in myopathy the movements are very uncertain. The children are apt to fall heavily when the centre of gravity is suddenly displaced, because their upright posture is maintained by balancing the trunk upon the support of the pelvis. The frequency and severity of the falls which these children suffer is a common complaint of the mother. The faulty posture is often associated with slight albuminuria. Its appearance is very capricious, but it is dependent to a great extent upon the assumption of the erect posture. There has been much discussion as to its explanation. It has been argued that the lordosis itself produces the albuminuria by mechanical compression of the renal vein, and it is said that albuminuria can be produced, even in the prone position, by placing the child in a plaster jacket applied so as to maintain the position of lordosis. Other observers, however, have not obtained this result. It seems most likely that the albuminuria is due to defective tone in the vasomotor musculature, comparable in every way to the defective tone in the muscles of the skeleton. We have often further evidence of vasomotor weakness. Fainting attacks are so common as to be the rule rather than the exception. Again, mothers are likely to complain of the child's pallor and of dark lines under the eyes, especially after exertion or in the reaction which follows excitement of any sort. As a rule a blood count will not show any very striking evidence of true anæmia. The pallor is of vasomotor origin, determined by faults in the distribution of the blood from vasomotor weakness and not by deficient blood formation. Circulatory and vasomotor disturbance probably also accounts for the dyspeptic pains and vomiting which commonly accompany any emotional excitement, or follow any unusual exertion or fatiguing experience. Constipation is a common, and mucous diarrhoea an occasional, symptom. The abdomen is often pigmented. The hands and feet are usually cold and cyanosed.

The extreme nervousness of the children is the point upon which most stress may be laid in the present connection. The association of albuminuria with neurosis in childhood has been noticed by many observers. The gastric and intestinal symptoms are especially characteristic. If the condition of the children is not materially improved, and if the symptoms, both of the physical defect and of the nervous disturbance, are not cut short, we may predict that in adult age their lives will be made miserable by a variety of abdominal symptoms dependent both on the vasomotor disturbance and upon the accompanying neurosis. Now that surgery forms so large a part of our therapeutic proceedings, they may not reach middle life without being submitted to one or more surgical operations. With good management both on the physical side and on the moral or psychological side they can be made into strong and useful members of society.

The treatment of these cases may be summed up as follows:

(a) We must search for any source of infection, a source which is often to be found in the condition of the tonsils. Enucleation may then be indicated as the first step in treatment.

(b) Massage and gymnastic exercises calculated to improve the muscular tone, while every effort is made to secure for the child as perfect hygiene in the environment as possible.

(c) The stimulating effect of cold douches is often very evident in improving the vasomotor tone. These children, however, will not stand well the abstraction of heat from their thin and chilly little bodies, so that it is a good plan before the colder douche to immerse the child in a hot bath and to return again to the bath momentarily afterwards. With these precautions children will often enjoy a cold spray, the temperature of which may be constantly lowered as they become used to it. Prolonged hot bathing has a correspondingly prejudicial effect.

(d) We must be on the watch to prevent the development of further postural deformities, such as scoliosis. If a child of strong muscular tone and good physique habitually adopts some posture, curled up, it may be, in some favourite easy-chair, there is little likelihood that its constant assumption will produce deformity. When the muscular system is lax and weak, on the other hand, deformity such as scoliosis is very readily caused. It is important, for example, to see that the child does not habitually incline to one side in reading or writing. When there is little energy for free and energetic play the children are apt to become great bookworms. If there is shortsightedness, the dangers are correspondingly increased. A special chair may be made with a well-fitting back and the seat a little tilted upwards so as to throw the child's trunk on to the support of the back. Lastly, a desk, the height of which can be regulated at will, can be swung into the proper position. The child, sitting straight and square, with the weight supported by the foot-rest and back as well as by the seat of the chair, should be taught to write with an upright hand, avoiding the slope which leads to sitting sideways with the left shoulder lowered.

(e) Malt extract, cod liver oil, Parrish's food, and other tonics may be of undoubted service.

(3) Rheumatism and Cholera

It is certain that there is a close association between rheumatism in childhood and the common nervous affection known as chorea. We are still ignorant of the precise nature of the infection which we know as rheumatism. There is much to suggest that in rheumatism we have to deal only with a further stage in those catarrhal infections to which so much infantile ill-health is to be attributed, and that endocarditis and arthritis, when they arise, signalise the entry of these catarrhal, non-pyogenic organisms into the blood stream, overcoming at last the barrier of lymphoid tissue which has hypertrophied to oppose their passage. Certainly the connection of rheumatism with catarrhal infections of the mucous membranes and adenoid enlargements of all sorts is a close one. Whatever its nature, the rheumatic infection in childhood is more lasting and chronic than in adult life. Rheumatism in childhood is not manifested by acute and short-lived attacks of great severity so much as by a long-continued succession of symptoms of a subacute nature, a transient arthritis, perhaps, succeeding an attack of sore throat with torticollis, to be followed by carditis, to be followed again by another attack of tonsillitis. And so the cycle of symptoms revolves. In most cases the child grows thin and weak; in most cases he becomes restless, irritable, and unhappy; often there is definite chorea. Of this cerebral irritability chorea is the expression. In adults, chorea is perhaps more obviously associated with mental stress of all sorts and with states of excitement and agitation. In the case of little children it is often only the mother who really appreciates how radical an alteration the child's whole nature has undergone, and how great the element of nervous overstrain has been before the chorea has appeared.

Of the treatment of chorea there is no need to speak. It is purely symptomatic. Isolation, best perhaps away from home, as might be expected, gives the best results. If there are pronounced rheumatic symptoms, the salicylates will be needed; if there is anæmia, arsenic and iron; if there is sleeplessness and great restlessness, bromides or chloral. Hypnotism is often almost instantly successful, but, apart from hypnosis, curative suggestions proceeding from the attendants form the principal means at our disposal.

(4) Exhaustion and Katatonia

A large number of children, in convalescence from infective disorders, when the nutrition of the body has fallen to a low ebb, show as evidence of cerebral exhaustion a group of symptoms which in a sense are the reverse of those which characterise cerebral irritation and chorea. The healthy child is a creature of free movement. The children we are now considering will sit for a long time motionless. The expression of their faces is fixed, immobile, and melancholy. If the arm or leg is raised it will be held thus outstretched without any attempt to restore it to a more natural position of rest for minutes at a time. The posture and expression remind us at once of the katatonia which is symptomatic of dementia præcox and other stuporose and melancholiac conditions in adult life. Symptoms of this sort are especially common in children with intestinal and alimentary disturbances of great chronicity.

The symptom is so frequently met with that it is strange that it should have attracted so little attention as compared with the contrasting condition of chorea. And yet it is of more serious significance, more difficult to overcome, and with a greater danger that permanent symptoms of neurasthenia will result. In early childhood a careful dietetic régime, suitable hygienic surroundings, and a stimulating psychical atmosphere will often effect great improvement. As in chorea, however, relapses are frequent, and there are cases which for some unexplained reason are peculiarly resistant to all remedial influences.

(5) Hysteria

In hysteria, in contrast to the types previously described, the infective element may be completely absent. Except in some special features of minor importance the symptoms of hysteria do not differ from those of adults, and, as in adult age, the condition of hysteria may be present although the physical development may be perfect. We cannot here speak of any physical characteristics which are associated with the nervous symptoms.

The third or fourth year represents the age limit, below which hysterical symptoms do not appear. Thereafter they may be occasionally met with, with increasing frequency. At first, in the earlier years of childhood, there is no preponderance in the female sex. As puberty approaches, girls suffer more than boys.

It may be said to be characteristic of hysteria in childhood that its symptoms are less complex and varied than in adult life. The naive imagination of the child is content with some single symptom, and is less apt to meet the physician half-way when he looks for the so-called stigmata. Similarly mono-symptomatic hysteria is characteristic of oases occurring in the uneducated or peasant class. In children, hysterical pain, hysterical contractures or palsies, mutism, and aphonia are the most usual symptoms. Hysterical deafness, blindness, and dysphagia are manifestations of great rarity in childhood.

CHAPTER XII

THE NERVOUS CHILD IN SICKNESS

In time of sickness the management of the nervous child becomes very difficult. Restlessness and opposition may reach such a pitch that it may be almost impossible to confine the patient to bed or to carry out the simplest treatment. Sometimes days may elapse before the sick-nurse who is installed to take the place of the child's usual attendant is able to approach the cot or do any service to the child without provoking a paroxysm of screaming. In such a case any systematic examination is often out of the question, with the result that the diagnosis may be delayed or rendered impossible. There is only one reassuring feature of a situation, which arises only in nurseries in which the management of the children is at fault; the doctor has learned from experience that this pronounced opposition of the child to himself, to the nurse, and even to the mother, is of itself a reassuring sign, indicating, as a rule, that the condition is not one of grave danger or extreme severity. When the child is more seriously ill, opposition almost always disappears, and the child lies before us limp and passive. Only with approaching recovery or convalescence does his spirit return and renewed opposition show itself.

Extreme nervousness in childhood carries with it a certain liability towards what is known as "delicacy of constitution." The sensitiveness of the children is so great that they react with striking symptoms to disturbances so trivial that they would hardly incommode the child of more stable nervous constitution. For example, a simple cold in the head, or a sore throat, may cause a convulsion or a condition of nervous irritability which may even arouse the suspicion that meningitis is present. Or, again, a little pharyngeal irritation which would ordinarily be incapable of disturbing sleep may be sufficient to keep the child wide awake all night with persistent and violent coughing. The little irritating papules of nettlerash from which many children suffer are commonly disregarded by busy, happy children during the day, and even at night hardly suffice to cause disturbance. The nervous child, on the other hand, will scratch them again and again till they bleed, tearing at them with his nails, and making deep and painful sores.

The temperature is commonly unstable and readily elevated. Moreover, feverishness from whatever cause is often accompanied by an active delirium, which is apt to occasion unnecessary alarm. This symptom of delirium is always a manifestation of an excitable temperament. I remember being called to see a young woman who was thought to be suffering from acute mania. Examination showed that she was suffering from pneumonia in the early stages. It was only later that we discovered that she had always been of an unstable nervous temperament, and had been in an asylum some years before. Those of us who are fortunate in possessing a placid temperament and have developed a high degree of self-control are not likely to show delirium as a prominent symptom should we fall ill with fever; just as we should not struggle and scream too violently when we "come round" from having gas at the dentist's. Looked at from this point of view, it is natural for all children to become delirious readily, and this tendency is peculiarly marked in those who are unduly nervous.

As a consequence of this extreme sensitiveness, the nervous child is likely to suffer more than others from a succession of comparatively trifling ailments and disturbances. The delicacy of the child has, in this sense, a real existence, and is not confined to the imagination of over-anxious and apprehensive parents. No doubt the nervous mother of an only child does worry unnecessarily, and is far too prone to feed her fears by the daily use of the thermometer or the weighing-machine; but her friends who are happy in the possession of numerous and placid children are not justified in laying the whole blame upon her too great solicitude. Children who are members of large families, whose nervous systems have been strengthened by contact with their brothers and sisters, are not habitually upset by trifles, and suffer even serious illnesses with symptoms of less severity. Nervous children, and only children, on the other hand, show the opposite extreme. Nevertheless, the mother of a nervous and delicate child—a child, that is to say, who, even if he is not permanently an invalid, nevertheless never seems quite well and lacks the robustness of other children—should realise clearly how much of this sensitiveness is due to the atmosphere of unrest and too great solicitude which surrounds him. It is a matter of universal experience that excess of care for only children has a depressing influence which affects their character, their physical constitution, and their entire vitality. At all costs we must hide our own anxieties from the child, and we must treat his illnesses in as matter-of-fact a way as possible.

When illness comes, his daily routine should be interrupted as little as possible. In dealing with nervous children, it is often better to lay aside treatment altogether rather than to carry out a variety of therapeutic procedures which have the effect of concentrating the child's mind upon his symptoms. When we grown-up people are sick, we often find a great deal of comfort in submitting ourselves to some form of treatment. We have great faith, we say, in this remedy or in that. It is our remedy, a nostrum. The physician knows well that the opportunities which are presented to him of intervening effectually to cut short the processes of disease by the use of specific cures are not very numerous, and that often enough the justification for his prescription is the soothing effect which it may exercise upon the mind of the patient, who, believing either in the physician or in his remedy, finds confidence and patience till recovery ensues. As a rule this form of consolation is denied to little children. They have no belief in the efficacy of the remedies which are applied with such vigour and persistence. Indeed, it is not the child, but his anxious mother, who finds comfort in the thought that everything possible has been done. Therefore, a prescription must be written and changed almost daily, the child's chest must be anointed with oil, and the air of the sick-room made heavy with some aromatic substance for inhalation, and all this when the disturbance is of itself unimportant, and owes its severity only to the undue sensitiveness of the child's nervous system.

The very name of illness should be banished from such nurseries. Everything should be done to reassure the child and to make light of his symptoms, and we can keep the most scrupulous watch over his health without allowing him to perceive at all that our eye is on him. With older children the evil results of suggestions, unconsciously conveyed to them by the apprehension of their parents, become very obvious. The visit of the doctor, to whom in the child's hearing all the symptoms are related, is often followed by an aggravation which is apt to be attributed to his well-meant prescription. The harm done by examinations, which are specially calculated to appeal to the child's imagination, as, for instance, an X-ray examination, is often clearly apparent. I remember a schoolboy of thirteen who was sent to me because he had constantly complained of severe abdominal pain. He was a nervous child with a habit spasm, the son of a highly neurotic father and an overanxious mother. An X-ray examination was made, but showed nothing amiss. The child's interest and preoccupation in the examination was painfully obvious. That night his restraint broke down altogether, and he screamed with pain, declaring that it had become insupportable. Younger children, less imaginative but equally perverse, noticing how anxiously their mothers view their symptoms, will often make complaint merely to attract attention and to excite expressions of pity or condolence. Sometimes they will enforce their will by an appeal to their symptoms. I have had a little patient of no more than thirteen months of age who suffered severely and for a long time from eczema, and who in this way used his affliction to ensure that he got his own way. If he was not given what he wanted immediately he would fall to scratching, with an expression upon his face which could not be mistaken. To him, poor child, the grown-up people around seemed possessed of but one desire—to stop his scratching; and he had learnt that if he showed himself determined to scratch they would give way on every other point.

The ill-effects of departing too readily from ordinary nursery routine on account of a little illness, and of adopting straightway a variety of measures of treatment, is well shown in cases of asthma in children. The asthmatic child is almost always of a highly nervous temperament, and often passionate and ungovernable. Often the most effective treatment of an attack, which usually comes on some hours after going to bed, is to make little of it, to talk naturally and calmly to the child, to turn on the light, and to allow him, if he will, to busy himself with toys or books. To be seized with panic, to send post-haste for the doctor, to carry the patient to the open window, to burn strong-smelling vapours, and so forth, not only is apt to prolong the nervous spasm on this occasion, but makes it likely that a strong impression will be left in his mind which by auto-suggestion will provoke another attack shortly. With nervous children a seeming neglect is the best treatment of all trivial disorders. Meanwhile we can redouble our efforts to remedy defects in management, and to obtain an environment which will gradually lower the heightened nervous irritability.

When the illness is of a more serious nature, as has been said, the restlessness as a rule promptly disappears. In each case it must be decided whether it is best for the child to be nursed by his mother and his own nurse, or by a sick-nurse. In the latter event the ordinary nurse and the mother should absent themselves from the sick-room as much as possible. Often the firm routine of the hospital nurse is all that is wanted to obtain rest. Less often, the child will be quiet with his own nurse, and quite unmanageable with a stranger.

There is, however, another side to the question. The relation of neurosis in childhood to infection of the body is complex. I have said that with the nervous child a trivial infection may produce symptoms disproportionately severe. Persistent and serious infection, however, is capable of producing nervous symptoms even in children who were not before nervous, and we must recognise that prolonged infection makes a favourable soil for neuroses of all sorts. The frequency with which St. Vitus's dance accompanies rheumatism in childhood forms a good example of this tendency. The child who, from time to time, complains of the transient joint pains which are called "growing pains," and who is found by the doctor to be suffering from subacute rheumatism, is commonly restless, fretful, and nervous. Appetite, memory, and the power of sustained attention become impaired. Often there is excessive emotional display, with, perhaps, unexplained bursts of weeping. The child is readily frightened, and when sooner or later the restless, jerky movements of St. Vitus's dance appear, the usual explanation is that some shock has been experienced, that the child has seen a street accident, has been alarmed by a big dog jumping on her, or by a man who followed her—shocks which would have been incapable of causing disturbance, and which would have passed almost unappreciated had not the soil been prepared by the persistent rheumatic infection.

The management of the nervous child whose physical health remains comparatively good is difficult enough, but these difficulties are increased many times when the physical health seriously fails. To steer a steady course which shall avoid neglecting what is dangerous if neglected, and overemphasising what is dangerous if over-emphasised, calls for a great deal of wisdom on the part both of the mother and her doctor.