Let us study briefly a third quality of the child which, for want of a better name, I have called after the ruling passion of mankind, his love of power. Perhaps it would be better to call it his love of being in the centre of the picture. It is his constant desire to make his environment revolve around him and to attract all attention to himself. Somewhat later in life this desire to attract attention, at all costs, is well seen in the type of girl popularly regarded as hysterical. The impulse is then a morbid and debased impulse; in the child it is natural and, within limits, praiseworthy. A girl of this sort, who feels that she is not likely to attract attention because of any special gifts of beauty or intellect which she may possess, becomes conscious that she can always arouse interest by the severity of her bodily sufferings. The suggestion acts upon her unstable mind, and forthwith she becomes paralysed, or a cripple, or dumb, presenting a mimicry or travesty of some bodily ailment with which she is more or less familiar. "Hysterical" girls will even apply caustic to the skin in order to produce some strange eruption which, while it sorely puzzles us doctors, will excite widespread interest and commiseration. Now little children will seldom carry their desire to attract attention so far as to work upon the feelings of their parents by simulating disease. They have not the necessary knowledge to play the part, and even if they make the attempt, complaining of this or that symptom which they notice has aroused the interest of their elders, the simulation is not likely to be so successful as to deceive even a superficial observer. But within the limits of their own powers, children are past masters in attracting attention. The little child is unable to take part in any sustained conversation; most of his talking, indeed, is done when he is alone, and is addressed to no one in particular. But he knows well that by a given action he can produce a given reaction in his mother and nurse. A great part of what is said to him—too great a part by far—comes under the category of reproof or repression. He is forbidden to do this or that, coaxed, cajoled, threatened long before he is old enough to understand the meaning of the words spoken, although he knows the tone in which they are uttered and loves to produce it at will. How he enjoys it all! Watch him draw near the fire, the one place that is forbidden him. He does not mean to do himself harm. He knows that it is hot and would hurt him, but for the time being he is out of the picture and he is intent on producing the expected response, the reproof tone from his mother which he knows so well. He approaches it warily, often anticipating his mother's part and vigorously scolding himself. He desires nothing more than that his mother should repeat the reproof, forbidding him a dozen times. The mind of all little children tends easily to work in a groove. It delights in repetition and it evoking not the unexpected but the expected. If his sport is stopped by his mother losing patience and removing him bodily from the danger zone, his sense of impotence finds vent in passionate crying. But if his mother takes no notice, the sport soon loses its savour. He is conscious that somehow or other it has fallen flat, and he flits off to other employment.
Mothers will complain that children seem to take a perverse pleasure in evoking reproof, appeals, entreaties, and exhortations. A small boy of four who had several times repeated the particular sin to which his attention had been directed by the frequency of his mother's warnings and entreaties, finding that on this occasion she had decided to take no notice, approached her with a troubled face: "Are you not angry?" he said; "are you not disappointed?" In reality the naughty child is often only the child who has become master of his mother's or his nurse's responses, and can produce at will the effect he desires. The idea that the child possesses a strong will, which can and must be broken by persistent opposition, is based upon this tendency of the child. It is an entire misconception of the situation: Strength of will and fixity of purpose are among the last powers which the human mind develops. In little children they are conspicuously absent. What appears to us as a fixed and persistent desire to perform a definite action in spite of all we can say or do, is often no more than the desire to produce the familiar tones of reproof, to traverse again the familiar ground, to attract attention and to find himself again the centre of the picture. If no one pays any attention and no one reproves, he soon gives up the attempt. If too much is made of any one action of the child, a strong impression is made on his mind and he cannot choose but return to it again and again.
This little drama of the fireplace may teach us a great deal in the management of children. The wise mother and nurse will find a hundred devices to catch the child's attention and lure him away from the danger zone without the incident making any impression on his mind at all, and will not call attention to it by repeated reproofs or warnings which will certainly lead him straight back to the spot.
In matters of greater moment the same impulse to oppose the will of those around him is seen. In considering the point of the child's susceptibility to suggestion, we have mentioned the refusal of sleep and the refusal of food. In both it is possible to detect the influence of this pronounced force of opposition. As the child lies sobbing or screaming in bed, every new approach to him, every fresh attempt at pacification, renews the force of his opposition in a crescendo of sound. But it is in his refusal of food that the child is apt to find his chief opportunity. Meal-times degenerate into a struggle. There at least he can show his complete mastery of the situation. No one can swallow his food for him, and he knows it. He can clench his teeth and shake his head and obstinately refuse every morsel offered. He can hold food in his mouth for half an hour at a time and remain deaf to all the appeals of his helpless nurse. If she tries force, he quells the attempt by a storm of crying. If she declines upon entreaty and coaxing, he will not be persuaded. It is the little scene of the fireplace over again. The attempts at force or the attempts at persuasion, by making much of it, have concentrated the attention of the child upon the difficulty, and have taught him his own power to dominate the situation.
It is right that parents should realise that the disturbing and irritating element in the child's environment is nearly always provided by the intrusion of the adult mind and its contact with the child's. Some supervision and some intrusion, therefore, is of course absolutely necessary, but the best-regulated nursery is that in which it is least evident. Something is definitely wrong if a child of two years will not play for half an hour at a time happily and busily in a room by himself. It is an even better test if the child will play amicably by himself with nurse or mother in the room, without the two parties crossing swords on a single occasion, without reproof or repression on the one side or undue attempts to attract attention on the other. If the child is entirely dependent upon the participation of grown-up persons in his pursuits, then not only do those pursuits lose much of their educative force, but they become a positive source of danger because of the constant interplay of personality with personality. The child who, seated on the ground, will play with his toys by himself, rises with a brain that is stimulated but not exhausted. Only very rarely do we find that solitary play, or play between children, is too exciting. In older children of very quick intelligence and nervous temperament we occasionally find that the pace which they themselves set is too exciting or exhausting. I recall a little boy of seven, an only child of particularly wise and thoughtful parents, who was brought to me with the complaint that he exhausted himself utterly both in body and mind by the intense nervous energy which he threw into his pursuits. For instance, he had been interested in the maps illustrating the various fronts in the European War, with which the walls of his father's study were hung, and although left entirely by himself he had become intensely excited and exhausted by the eagerness with which he had spent a whole morning, with a wealth of imaginative force, in drawing a map of the garden of his house and converting it into the likeness of a war map, filled with imaginary Army Corps. Such excessive expenditure of nervous force is unusual even in older children, and as in this case is found usually only when there is a pronounced nervous inheritance. In little children in the nursery, solitary play or play between themselves seldom produces nervous exhaustion. It is quite otherwise when the child is dependent to a too great extent upon the participation of adults. It is almost impossible for the mother and nurse not to take the leading part in the exchange of ideas, and no matter what may be their good intentions, the pace set is apt to be too great. Environment, without the intrusion of the adult mind, is best able to adjust the necessary stimulus and produce development without exhaustion. Play with grown-up persons, the reading aloud of story books, the showing of pictures, and so forth, undoubtedly have their own importance, but they should be confined within strict limits and to a definite hour in the daily routine. There is sometimes too great a tendency for parents to make playthings of their little children. Save at stated times, they must curb their desire to join in their games, to gather them in their arms, to hold them on their knee, while they stimulate their minds by a constant succession of new impressions. With an only child, whose existence is the single preoccupation of the nurse and mother, and, often enough, of the father as well, it is difficult to avoid this fault. Yet, if wisdom is not learnt, the damage to the child may be distressingly serious. He rapidly grows incapable of supporting life without this excessive stimulation. Without the constant society and attention of a grown person, he feels himself lost. He cannot be left alone, and yet cannot enjoy the society he craves. He grows more and more restless, dominating the whole situation more and more, constantly plucking at his nurse's skirts, perversely refusing every new sensation that is offered him to still his restlessness for a moment. The result of all this stimulation is mental irritability and exhaustion, which in turn is often the direct cause of refusal of food, dyspepsia, wakefulness, and excessive crying.
The devices by which children will attract to themselves the attention of their elders, and which, if successful, are repeated with an almost insane persistence, take on the most varied forms. Sometimes the child persistently makes use of an expression, or asks questions, which produce a pleasant stir of shocked surprise and renewed reproofs and expostulations. One little boy shouted the word "stomachs" with unwearied persistence for many weeks together. A little girl dismayed her parents and continued in spite of all they could do to prevent her to ask every one if they were about to pass water.
Disorders of conduct of this sort are not really difficult to control. Suitable punishment will succeed, provided also that the child is deprived of the sense of satisfaction which he has in the interest which his conduct excites. His behaviour is only of importance because it indicates certain faults in his environment and a certain element of nervous unrest and overstrain.
The young child demands from his environment that it should give him two things—security and liberty. He must have security from shocks to his nervous system. It is true that from the greater shocks the children of the well-to-do are as a rule carefully guarded. No one threatens or ill-uses them. They are not terrified by drunken brawls or scenes of passion. They are not made fearful by the superstitions of ignorant people. Nevertheless, by the summation of stimuli little emotions constantly repeated can have effects no less grave upon their nervous system. From this constantly acting irritation the child needs security. In the second place, he requires liberty to develop his own initiative, which should be stimulated and sustained and directed. Without liberty and without security conduct cannot fail to become abnormal.
Before we proceed to a closer examination of the various symptoms of nervous unrest in detail, we may very briefly consider the scope and power of the child's understanding. As a rule I am sure that it is grossly underestimated. The mental processes of the child are far ahead of his power of speech. The capacity for understanding speech is well advanced, and an appeal to reason is often successful while the child is still powerless to express his own thoughts in words. Because he cannot so express himself there is a tendency to underestimate the acuteness of his reasoning, to talk down to him, and to imagine that he can be imposed upon by any fiction which seems likely to suit the purpose of the moment. A child of eighteen months is not too young to be talked to in a quiet, straightforward, sensible way. Only if he is treated as a reasonable being can we expect his reasoning faculties to develop. Children dislike intensely the unexplained intervention of force. If a pair of scissors, left by an oversight lying about, has been grasped, the first impulse of the mother is to snatch the danger hurriedly from the child's hands, and her action will generally be followed by resistance and a storm of weeping. She will do better to approach him quietly, telling him that scissors hurt babies, and show him where to place them out of harm's way. Watch a child at play after his midday meal. He has been out in his perambulator half the morning, and for the other half has been deep in his midday sleep. Now that dinner is over he is for a moment master of his time and busily engaged in some pursuit dear to his heart. At two o'clock inexorable routine ordains that he must again be placed in the perambulator and wheeled forth on a fresh expedition. If the nurse does not know her business she will swoop down upon him, place him on her knee, and begin to envelop his struggling little body in his outdoor clothes, scolding his naughtiness as he kicks and screams. If she has a way with children she will open the cupboard door and call on him to help find his gaiters and his shoes because it is time for his walk. In a moment he will leave his toys, forgetting all about them in the joy of this new activity.
If the reason for things is explained to children they grow quick to understand quite complicated explanations. A little girl, not yet two, was playing with her Noah's Ark on the dining-room table with its polished surface. The mother interposed a cloth, explaining that the animals would scratch the table if the cloth were not there. Within a few minutes the child twice lifted the cloth, peering under it and saying, "Not scratch table." Yet how often do we find facetiously-minded persons confound their reasoning and confuse their judgment by foolish speeches and cock-and-bull tales, which, just because of their foolishness, seem to them well adapted to the infant intelligence.
An attempt to deceive the child is almost always wrong, and because of our tendency to underestimate the child's intelligence it generally fails. If a little girl has a sore throat, and the doctor comes to see her, she knows quite well that she is the prospective patient. It is useless for the mother to begin proceedings by trying to convince her that this is not so—that mother has a sore throat too. Such a plan only arouses apprehension, because the child scents danger in the artifice.
Closely connected with the reasoning powers of the child is the difficult question of the growth of his appreciation of right and wrong, or, to put it in another way, the growth of obedience or disobedience. Sooner or later the child must learn to obey; on that there can be no two opinions. Nevertheless, I think there can be no doubt that far more harm is done by an over-emphasis of authority than by its neglect. If the nurse or mother is of strong character, and the authority is exercised persistently and remorselessly, so that the whole life of the child is dominated, much as the recruit's existence in the barrack yard is dominated by the drill sergeant, his independence of nature is crushed. He is certain to become a colourless and uninteresting child; he runs a grave risk of growing sly, broken-spirited, and a currier of favour. If a child is ruthlessly punished for disobedience from his earliest years, there is, it need hardly be said, a grave risk that he will learn to lie to save his skin. I have seen a few such cases of what I may call the remorseless exercise of authority, and the result has not been pleasing. Fortunately, perhaps, not many women have the heart to adopt this attitude to the waywardness of little children—a waywardness to which their whole nature compels them by their pressing need to cultivate tactile sensations, to experiment, and to explore. Therefore, much more commonly, the authority is exercised intermittently and capriciously, with the result that the child's judgment is clouded and confused. Conduct which is received indulgently or even encouraged at one moment is sternly reprimanded at another. Every one who has the management of little children must above all see to it, whatever the degree of stringency in discipline which they decide to adopt, that their attitude is always consistent. The less that is forbidden the better, but when the line is drawn it must be adhered to. If once the child learns that the force which restrains him can be made to yield to his own efforts, the future is black indeed. From that day he sets himself to strike down authority with a success which encourages him to further efforts. I have known a child of five years terrorise his mother and get his own way by the threat, "I will go into one of my furies."
The difficulty of successfully enforcing authority, and of carrying off the victory if that authority is disputed, should make mothers wary of drawing too tight a rein. The conflict between parent and child must always be distressing and must always be prejudicial to the child, whatever its outcome, whether it brings to him victory or defeat. He learns from it either an undue sense of power or an undue sense of helplessness, and the knowledge of neither is to his benefit. Although frequently worsted in the conflict, nurses will often return to the attack again and again and hour after hour, restraining, reproving, forbidding, and even threatening. Nor do they see that they are really goading the children into disobedience by their misdirected efforts at enforcing discipline. Reproof, like punishment, loses all its effect when it is too often repeated, and the child soon takes it for granted that all he does is wrong, and that grown-up people exist only to thwart his will, to misunderstand, to reprove, or even to punish.
In the nursery the word "naughty" is far too frequently heard. It is naughty to do this, it is naughty to do that. There is no gradation in the condemnation, and the child loses all sense of the meaning of the word. He himself proclaims himself naughty almost with satisfaction: his doll is naughty, the dog is naughty, his nurse and mother are naughty, and so forth. In reality the little child is peculiarly sensitive to blame, if he is not reproof-hardened. It is hardly necessary to use words of blame at all. If he is asked kindly and quietly to desist, much as we would address a grown-up person, and does not, he can be made to feel that his conduct is unpopular by keeping aloof from him a little, by disregarding him for the time being, and by indicating to him that he is a troublesome little person with whom we cannot be bothered.
Any one who has had much to do with children will realise that, if wrongly handled, they are apt to take a positive delight in doing what they conceive to be wrong. There is clearly a delightful element of excitement in the process of being naughty, of daring and of braving the wrath to come, with which they are so familiar and for which they care nothing at all. But the perverseness of which we are now speaking has a different origin. It arises only when children are reproved, appealed to, and expostulated with too often and too constantly. Negativism is a symptom which is common enough in certain mental disorders. The unhappy patient always does the opposite of what is desired or expected of him. If he be asked to stand up he will endeavour to remain seated, or if asked to sit he will attempt to rise to his feet. Like many other symptoms of nervous disturbance which we shall study later, this negativistic spirit is often displayed to perfection by little children when the environment is at fault and when grown-up people have too freely exercised authority. A mother, anxious to induce her little son to come to the doctor, and knowing well that her call to him to enter the room, as he stands hesitating at the door, will at once determine his retreat to the nursery, has been heard to say, "Run away, darling, we don't want you here," with the expected result that the docile child immediately comes forward. To the doctor, that such a device should be practised almost as a matter of course and that its success should be so confidently anticipated, should give food for thought. It may shed light on much that is to follow later in the interview.
The question of punishment, like that of reproof, is beset with difficulty. There are fortunately nowadays few educated mothers who are so foolish as to threaten punishment which they obviously do not intend to administer and which the child knows they will not administer. It is clear that punishment must be rare or else the child will grow habituated to it, and with little children we cannot be brutal or push punishment to the point of extreme physical pain. It is more difficult to say, as one is tempted to say, that all punishment is futile and should be discarded. Probably mothers are like schoolmasters in that no two schoolmasters and no two mothers obtain their effects in exactly the same way or by precisely the same means. Nor do all children accept reproof or submit to punishment in the same way. Some make light of it and take a pleasure in defying authority. Others are unduly cast down by the slightest adverse criticism. It is generally true that extreme sensitiveness to reproof is a sign of a certain elevation of character. Always we must remember that for a mother to inflict punishment, whether by causing physical pain or mental suffering, is to take on her shoulders a certain responsibility. It is a serious matter if she has misapprehended the child's act—if the sin was not really a sin, but only some perverted action, the intention of which was not sinful, but designed for good in the faulty reasoning of the child. A little girl, in bed with a feverish cold, was found shivering, with her night-dress wet and muddy. It was an understanding mother who found that her little brother, having heard somehow that ice was good for fevered heads, had brought in several handfuls of snow from the garden, not of the cleanest, and had offered them to aid his sister's recovery. It need hardly be said that punishment should always be deliberate. The hasty slap is nothing else than the motor discharge provoked by the irritability of the educator, and the child, who is a good observer on such points, discerns the truth and measures the frailty of his judge.
The frequent repetition of words of reproof and acts of punishment has a further disadvantage that the older children are quick to practise both upon their younger brothers and sisters. There is something wrong in the nursery where the lives of the little ones are made a burden to them by the constant repression of the older children. But although set and artificial punishments are as a general rule to be used but sparingly, the mother can see to it that the child learns by experience that a foolish or careless act brings its own punishment. If, for example, a child breaks his toy, or destroys its mechanism, she need not be so quick in mending it that he does not learn the obvious lesson. If the baby throws his doll from the perambulator, in sheer joy at the experience of imparting motion to it, she need not prevent him from learning the lesson that this involves also some temporary separation from it. Throughout all his life he is to learn that he cannot eat his cake and have it too. The use of rewards is also beset with difficulties. Their coming must be unexpected and occasional. They must never degenerate into bribes, to be bargained for upon condition of good behaviour. Rewards which take the form of special privileges are best.
The æsthetic sense of children develops very early. From the very beginning of the second year they take delight in new clothes, and in personal adornment of all sorts. They show evident pleasure if the nursery acquires a new picture or a new wall-paper. They have pronounced favourites in colours. Even tiny children show dislike of dirt and all unpleasant things. Personal cleanliness should be clearly desired by all children. A sense of what is pleasant and what is unpleasant should be encouraged. Any delay in its appearance is apt to imply a backwardness in development of mind or of body. Only children who are tired out by physical illness or by nervous exhaustion will lie without protest in a dirty condition.
Affection and the attempt to express affection appear clearly marked even in the first year. Too much kissing and too much being kissed is apt to spoil the spontaneity of the child's caresses. We must not, however, expect to find any trace in the young child of such a complex quality as unselfishness or self-abnegation. The child's conception of his own self has but just emerged. It is his single impulse to develop his own experience and his own powers, and his attitude for many years is summed up in the phrase: "Me do it." We must not expect him to resign his toys to the little visitor, or the little visitor to cease from his efforts to obtain them. In all our dealings with children we must know what we may legitimately expect from them, and judge them by their own standards, not by those of adult life. We cannot expect self-sacrifice in a child, and, after all, when we come to think of it, obedience is but another name for self-sacrifice. If the tiny child could possibly obey all the behests that are heaped upon him in the course of a day by many a nurse and mother, he would truly be living a life of complete self-abnegation. Surely it is because the virtue of obedience, the virtue that is proclaimed proverbially the child's own, is so impossible of attainment that it is become the subject of so much emphasis. As Madame Montessori has put it: "We ask for obedience and the child in turn asks for the moon." Only when we have developed the child's reasoning powers, by treating him as a rational being, can we expect him deliberately to defer his wishes to ours, because he has learned that our requests are generally reasonable.
The mind of the child is so unstable and yet so highly developed, that symptoms of nervous disturbance are more frequent and of greater intensity than in later life. Only rarely and in exceptional cases do certain symptoms, common in childhood, persist into adult life or appear there for the first time, and then usually in persons who, if they are not actually insane, are at least suffering from intense nervous strain. We have already mentioned the symptom of negativism and noted its occasional occurrence as an accompaniment of mental disorder in adult life, and its frequency among children who are irritable or irritated. Similarly, we may cite the digestive neuroses of adult life to explain the common refusal of food and the common nervous vomiting of the second year of life. Thus, for example, there exists in adult life a disturbance of the nervous system which is called "anorexia nervosa." A boy of nineteen was brought to the Out-patient Department of Guy's Hospital suffering from this complaint. He was little more than a skeleton, unable to stand, hardly able to sit, and weighing only four and a half stones. His mother, who came with him, stated that he had always been nervous, and that lately, after receiving a call to join the army as a recruit, his appetite, which had for some time been capricious, had completely disappeared. In spite of coaxing he resolutely refused all food, or took it only in the tiniest morsels, although at the same time it was thought that he sometimes took food "on the sly." A careful examination showed absolutely no sign of bodily disease. He was admitted to a ward for treatment by hypnotic suggestion, but before this could be begun he endeavoured to commit suicide by setting fire to his bed.
A girl of twenty-four years of age had become almost equally emaciated. Constant vomiting had persisted for many years and had defied many attempts at cure. It had even been proposed to perform the operation of gastro-enterostomy in the belief that some organic disease existed. In suitable surroundings and with the energetic support of a good nurse, who spent much time and care in restoring her balance of mind, the vomiting ceased, and she gained over two stones in weight. Work was found for her in some occupation connected with the War, and she left the Nursing Home to undertake this, bearing with her four pounds which she had abstracted from the purse of another patient.
Those who have not opportunities of observing how all-powerful is the effect of the mind upon the body, and especially perhaps upon the process of digestion, may find it hard to believe that these distressing symptoms and profound changes in the aspect and nutrition of the patients were due entirely to mental causes and were symptoms in accord with the attempted suicide or the theft of the money. In nervous little children we shall not often find such complex actions as suicide or theft, although they do occur, but combined with other evidence of nervousness we shall meet commonly enough with a persistent setting aside of appetite and refusal of food and with continuous and habitual vomiting, from nervous causes.
The experiments of Pawlow and others have explained the dependence of digestion upon mental states. They show that even before the food is taken into the mouth, while the meal is still in prospect, there has been instituted a series of changes in the wall of the stomach, which gives rise to the so-called psychic secretion of gastric juice. These changes are preceded by the sensation of appetite, which is evoked not by the presence of food in the stomach—for the food has not yet been swallowed—but by the anticipation of it, by the sight and smell of food, as well as by more complex suggestions, such as the time of day, the habitual hour, the approach of home, and so forth.
Emotional states of all sorts—grief, anger, anxiety, or excitement—put a stop to the process or interfere with its action, so that the sense of appetite is absent, and the taking of food is apt to be followed by discomfort or pain or vomiting. No doubt good digestion leads to a placid mind, but it is equally true that a placid mind is necessary for good digestion. Therefore we civilised people, living lives of mental stress and strain, try to increase the suggestive force of our surroundings and to provoke appetite by all devices calculated to stimulate the æsthetic sense. The dinner hour is fixed at a time when all work and, let us hope, all worry is at an end for the day. The dinner-table is made as pretty as possible, with flowers and sparkling glass. We are wise to dress for dinner, that with our working clothes we may put off our working thoughts.
In the treatment of adult dyspepsia we seldom succeed unless we can place the mind at rest. We may advise a visit to the dentist and a set of false teeth, or we may administer a variety of stomach tonics and sedatives, but if the mind remains filled with nameless fears and anxieties we shall not succeed.
In adult life the nervous person when subjected to excessive stress and strain is seldom free from dyspeptic symptoms of one sort or another, and what is true of adult life is even more true of childhood, when the emotions are more poignant and less controlled. Then tears flow more readily than in later life, and tears are not the only secretions which lie under the influence of strong emotion. Emotional states, which would stamp a grown man as a profound neurotic, are almost the rule in infancy and childhood, and may be marked by the same physical disturbances—flushing, sweating, or pallor, by the discharge of internal glandular secretions as well as by inhibition of appetite, by vomiting, gastric discomfort, or diarrhoea. Naturally enough, mothers and nurses are wont to demand a concrete cause for the constant crying of a little child, and teething, constipation, the painful passage of water, pain in the head, or colic and indigestion are suggested in turn, and powders, purges, or circumcision demanded. There can be no doubt that nervous unrest is capable of producing prolonged dyspepsia in infancy and childhood—a dyspepsia which, while it obstinately resists all attempts to overcome it by manipulation of the diet, is very readily amenable to treatment directed to quiet the nervous system.
Where a primary dyspepsia exists for any length of time, the growth and the nutrition of the child is clearly altered for the worse. The character of the stools, their consistency, smell, and colour, is apt to be changed because the bacterial context of the bowel has become abnormal. Rickets, mucous disease, lienteric diarrhoea, infantilism, prolapse of the rectum, and infection with thread-worms are common complications. No doubt children with primary dyspepsia are often nervous and restless, and the elements of infection and of neurosis are frequently combined. Yet often we meet with cases in which the gastric or intestinal disturbance comes near to being a pure neurosis. The nutrition, then, seldom suffers to any very great extent, or to a degree in any way comparable to that which is characteristic of dyspepsia from other causes. Emaciation, wrinkling of the skin, dryness and falling out of the hair, decay of the teeth, are not as a rule part of the picture of nervous dyspepsia. The child may be slim and thin and nervous looking, but as a rule he is active enough, with a good colour and fair muscular tone, so that one has difficulty in believing the mother's statements, which are yet true enough, as to the trouble which is experienced in forcing him to eat, or as to the frequency of vomiting.
In early childhood the difficulty of the refusal of food often passes or diminishes when the child learns to feed himself with precision and certainty. To teach him to do so, it is not wise to devote all our attention to making him adept at this particular task. The fault is that the brain centres which control the movements of hands, mouth, and tongue have not been developed, because his activities in all directions have not been encouraged. It is much less trouble for a nurse to feed a little child than to teach him to feed himself, and if he is not given daily opportunities of practice he will certainly not learn this particular action. But the fault as a rule lies deeper. The child who cannot feed himself cannot be taught until fingers and brain have been developed in the thousand activities of his daily routine, by which he acquires general dexterity. A child who is still too young to feed himself is learning the dexterity which is necessary as a preliminary in every action of the day. If he can carry the tablecloth and the cups and saucers to the tea-table, imitating in everything the action of his nurse, it will be strange if he does not also imitate her in the central scene, the actual eating of the food. If, on the other hand, he is waited upon hand and foot, if he is restrained and confined, sitting too much passively, now in his perambulator, now in his high chair, now on his nurse's lap, his imitative faculties and his tactile dexterity alike remain undeveloped. The child who is slow in learning to feed himself shows his backward development in every movement of his body. One may note especially the stiff, "expressionless" hands, indicating a general neuro-muscular defect. I have seen many children of eighteen months or two years of age in whom the movements necessary for efficient mastication and swallowing had failed to develop satisfactorily. In some a pure sucking movement persisted, so that when, for example, a morsel of bread or rusk was put in the child's mouth, it would be held there for many minutes and submitted only to suction with cheeks and tongue. Attempts to swallow in such a case are so incoordinate that they give rise frequently to violent fits of choking, which distress the child and produce resistance and struggling, while at the same time they alarm the mother or nurse so much that further attempts to encourage the taking of solid food are hastily and for a long time abandoned. In this helpless condition the other factors which tend to develop what we have called negativism have full play. The want of imitation and the lack of dexterity is not the sole or perhaps the main cause of the child's refusal of food and of the apparent want of appetite, but it is the cause of the failure to learn to feed himself, which places him in a condition which is peculiarly favourable to the operation of other factors. If only we can teach the child to feed himself, the difficulties of the situation become much less formidable.
The first of the factors which encourage the persistent refusal of food is the extreme susceptibility of the child to suggestion. A particular article of diet may be refused on one occasion, perhaps in pique, because another more favoured dish was hoped for or expected, or perhaps because the taste is not yet familiar. Then if on this occasion a struggle for the mastery is waged, and a painful impression is made on the child's mind connecting this particular dish with struggling and tears, from that day forward the child may persistently refuse it on every occasion it is offered. Matters are made worse if the nurse, anticipating refusal, attempts to overcome the resistance by peremptory orders, or by excessive praise extolling the delicious flavour with such fervour that the child's suspicions are at once aroused. Previous experience has made him connect these excessive praises with articles which have aroused his distaste. If these fads and fancies on the part of the child are to be avoided, it is essential that we should do nothing to focus his attention on his refusal. It is better that his dinner should be curtailed on one occasion than that taste and appetite should be perverted perhaps for years. Every nurse or mother should cultivate an off-hand, detached manner of feeding the child, and should patiently continue to offer the food without uncalled-for comments or exhortations. Let her always remember the force of suggestion on the child's mind, and that a confident manner which never questions the child's acceptance will meet with acceptance, while a hesitating address, from fear of the impending refusal, will be apt to meet with refusal. Sometimes a still worse fault manifests itself, when nurse and mother speak before the child of the smallness of his appetite, and of his persistent refusal of this or that article of diet. The suggestion then acts still more powerfully on his mind. He is aware that the whole household is distressed by his peculiarity, and he grows to identify it with his own individuality, and to regard himself with some satisfaction as possessing this mark of distinction. If there is any difficulty of this sort it is often directly curative to reverse the suggestion and to speak before him of his improving appetite, and to say that he begins every day to eat better and better, even if to do so we have to break a good rule never to say to the child what is not strictly true. Or once or twice we may take his plate away before he has finished, saying positively that he has eaten so much that he must eat no more. If in spite of every care antipathies to certain articles of food appear and persist, we must be content to bide our time. When the child grows of an age to reason, we should seize every opportunity to make him feel that his persistent refusal is a little ridiculous and childish. Little by little the seed is sown, and will germinate till one day we shall note with surprise that he has taken of his own accord that which he has neglected for so long and with such obstinacy.
But the force which is acting most strongly in producing this refusal of food is the force of which we have spoken in a previous chapter—the force which results in negativism, the force which is in reality the habit of opposition, the love of power, and the desire to attract attention. Here again the refusal of food, if due to this cause, is never the sole manifestation of the fault. Just as the delay in learning to swallow and to chew properly and to feed himself is part of a general want of dexterity and capacity manifested in all his actions, so it will seldom happen that the child's anxiety to oppose is only seen at meal-times. Watch a nervous child in the nursery before the dinner hour. He is cross and restless and inclined to cry. The nurse hands him a doll, and he throws it away saying, "No, no doll." At the same moment he may catch sight of his ball, and it too is violently rejected, "No, no ball." Everything in turn is treated in the same way. Finally he falls upon his nurse, crying and beating her with his hands, saying, "No, no Nurse." If that long-suffering woman at that moment summons him to dinner, it will be strange indeed if his attitude is not "No, no dinner," and "No, no" to every mouthful offered him. How strong this love of opposition may be is illustrated by the case of a little boy who was brought to me for refusal of food. Three weeks before, he had been taken in a motor-car to his grandfather's to midday dinner on Sunday, when his absolute refusal of food had spoiled the day and had occupied the attention and the efforts of the whole party. Doubtless he had enjoyed himself, for three weeks later, when he caught sight of the car which was to bring him to me, and which he had not seen in the interval, he at once said, "Not eat my dinner." This child's father told me that the sight or sound of the preparation of a meal was enough to bring on a paroxysm of opposition. Now this force of opposition, as we have seen, only develops into a serious difficulty when the child's own will has been opposed too much, when authority has been too freely exercised, and when the child has been urged and entreated and reproved with too great frequency. His opposition grows with all counter-opposition. And he is not really naughty, only irritable and restless from the thwarting of his natural impulses, and unable to express his thoughts and desires. Negativism will not often confine itself to meal-times. It will show clearly in all the actions of the child, and to get him to eat well and freely we must so change our management of him that negativism disappears or at least diminishes. There is no other way. No entreaty, no force, no threats of force will ever succeed, but will only make him worse, and, since negativism is due to mental unrest, the struggles and crying will only perpetuate the cause. The one way to banish negativism and overcome the opposition is to cease to oppose, and to practise this aloofness not so much at meal-times, for somehow by patience the child must be got to take his food, but in all our conduct to him. Repression and reproof, and thwarting of the child's will, and coaxing and entreaty must cease. There is no fear that we shall thereby make the child unduly disobedient. We have already, in another chapter, decided that negativism is not strength of will on the part of the child which must be broken, but is the result of constant attempts to oppose his nature, and the consequent nervous unrest. If we cease to oppose, the symptoms will tend rapidly to disappear, the child will become busy and contented and happy in his play, and we shall hear no more of his refusal of food. If sometimes it recurs for a week or two, we shall know how to deal with it.
In children, as with us, periods of nervous unrest and unhappiness are apt to recur in a sort of cycle. This cyclical character of mental disturbance is often a marked feature. We see it in epilepsy and in what the French have called Folie Circulaire. We see it in the dipsomaniac, in the intermittency of his craving for drink and of his periodical outbursts, and we see it in ourselves in those periods of depression which recur so often, we know not why. Little children too sometimes get out on the wrong side of their beds, and never get right the whole long day. Their own experience of the vagaries of mental states should lead mothers to be indulgent to the children in their days of cloud and to be particularly careful not to goad them by well-intentioned efforts into bursts of naughtiness and passion, each one of which tends to perpetuate the condition and increase the nervous unrest. We know how closely dependent is the sensation of appetite upon emotional states, and we must do all in our power—and the task is sometimes one of real difficulty—to keep the child's mind sufficiently at rest to preserve the healthy desire for food unimpaired. If there is no sign of appetite, but every sign of restlessness and irritability, we must seek in the management of the child until we find the fault.
If food is taken mechanically and without appetite, if the preliminary changes in the stomach wall which are necessary for adequate digestion do not take place, but are inhibited by the mental unrest, the meal is apt to be followed by gastric pain and discomfort, or, more commonly with children, the stomach may promptly reject its contents. At the worst, nervous vomiting of this sort may follow almost every meal, although, again, it is curious to note how little, comparatively speaking, the nutrition of the child suffers. The vomiting too, as in adults, comes very near being a voluntary act, and mothers and nurses will often remark that they get the impression that it can be controlled at will. If once the diagnosis is made that the want of appetite or the vomiting is of nervous origin, the treatment of the condition is clear. Sedative drugs directed towards quieting the nervous excitability may be of service, but tonics, appetisers, laxatives, and drugs with a direct action on the stomach will have but little effect. Nor is there as a rule anything to be gained by modifying the diet or by excluding this or that article of food. The frequency of the vomiting is such that it is apt to have brought discredit one after the other upon almost every article of food which the child can take, with the result that many useful and necessary foods have been abandoned for long on the ground that they are the cause of the dyspepsia. A permanent cure will only be effected when the faults of environment have been overcome, when the cause of the nervous unrest has been removed, and when the child's mind is at peace.
Nervous vomiting of this kind is not difficult to control, if those in charge of the children can be made to understand that the cause lies in the anxiety which they themselves show before the child, increasing his own apprehension or adding to his sense of power or importance. Once the child is convinced that his conduct excites no particular interest, the vomiting soon ceases. In more than one instance, vomiting which has persisted for many months has stopped at once after the matter has been fully explained to the parents. In the most inveterate case of this sort which has come under my notice, the child was regularly sick as soon as he caught sight of a white cloth being laid on the table for meals. Yet even this child never vomited when he was under the charge of a particular nurse who had to return more than once to the family, and on each occasion was successful in breaking the habit.
So far, almost all that has been written—and there has been a great deal of unavoidable repetition—has been devoted to an attempt to determine the causes which lead the child to refuse food and the methods which we adopt to prevent or overcome the difficulty. Other neuroses may be studied in less detail, because they depend for their existence upon the same causes. For example, the habit of refusing sleep, which is as common and almost as distressing as the habit of refusing food, depends both upon a perversion of suggestion and upon the phenomenon that we have called negativism.
If struggling and crying has occurred upon a series of nights, the child comes to associate his bed not with sleep but with tears. If a mother values her peace of mind, if she would spare herself the discomfort of hearing her child sob himself nightly into uneasy sleep, she must be wary how this all-important event of going to bed is approached. With a nervous and restless child the preliminaries of preparing for bed must be managed carefully and tactfully. The hour before bedtime is almost universally the most interesting of the whole day for the child. Then the baby, with his best frock on, and books and toys, is the centre of interest in the drawing-room, till the clock strikes and the nurse appears at the door. Suddenly it is all over, and inexorable routine sends him off to bed. The good nurse will give the child a little time to recover from the shock of her arrival, and will not hurry him. She knows that his little mind is slow to act, and that he must be led gradually to face a new prospect. If she hurries him, catching him up in her arms from the midst of his unfinished pursuits, resistance and tears are almost sure to follow, and the difficult task of the day—the putting to bed—has made the worst possible start. When this has happened on one or two successive evenings, the habit of resistance to going to bed becomes fixed, and, like all bad habits, is difficult to break. A nurse who has a way with children will arouse his interest in a new pursuit, in which he can play the chief part, the putting away of his picture books and toys. If he is too small to carry his own chair or table to its allotted place in the room, at least he can show his learning by pointing out the spot. In the waving of good-byes he is expert and takes a legitimate pride, and upstairs he has learnt that there are new delights. He himself can turn on the taps in the bathroom, and he can set every article in the proper place ready for use. All children love their bath, and if interest and good temper has been so far preserved, without a break, it will be ill-fortune if even the drying process is not carried off without a hitch. Afterwards, for a little, nervous babies, whose brains still teem with all the excitements of the day, are best left to sit for a few moments by the nursery fire, while the nurse puts all the garments one by one to bed. Each as it goes to rest will be greeted by him with cheerful farewells; and so does the force of suggestion act, till the central figure himself plays his part in the scene, of which he feels himself the controller and director, and climbs to bed. But if there has been a hitch anywhere, if the bugbear of negativism has appeared, if he has been scolded or coaxed or repressed too much and there have been tears and struggles, then going to bed is a poor preparation for instant and quiet sleep.
With excitable, highly-strung children, the best laid plans and the most tactful nurse will not always succeed, and to place him in his cot is to provoke a storm of angry refusal and resistance. There are mothers who believe that the best way is then to turn out the light and leave the child to cry himself to sleep. This is a point on which no one can lay down rules which are applicable for all children. It may sometimes succeed, and the child may reason correctly and in the way we wish him to reason, deciding that the game is not worth the candle and so give it up. But with nervous, highly-strung children I doubt if this Spartan conduct is commonly successful. Often if the attempt is made, the troubled mother, listening to all these heart-breaking sobs, can bear it no longer, and goes back to the side of the cot to soothe and persuade him. Then certainly the longer she has restrained her natural inclination, the longer the child has sobbed himself into a pitiful little ball of perspiration and tears, the more difficult will be her task in quieting him, the stronger will be the impression formed on the child's mind, and the greater will be the suggestion which will act under the same circumstances to-morrow. Children who fall a prey to this uncontrolled crying, cry on because they cannot stop when they have begun. They do not then cry purposely or with a fixed intention, desiring to attain some object. They cry because their minds are not at rest, but are irritated and overwrought by the happenings of the day. We decided that it was useless to attempt by exhortations at meal-times to induce a nervous child to eat who habitually refuses food, and that we can only cure the condition by eliminating from his daily life the elements of repression and opposition which provoke the counter-opposition. And we must seek the same solution in this other difficulty of the refusal of sleep. It is useless to attempt to treat the symptom of refusal of sleep and to leave the cause of that symptom still constantly in action.
If, in spite of our care to avoid unrest and irritation of the child's brain, sleep is refused, as may often happen, it is, as a rule, wise to cut short the crying if we can, before a vicious circle has been formed and the unrest has been intensified by the emotional storm. It is useless with little children to urge them to go to sleep or to coax. It is not usually wise to leave the child for a little and then to return. Each time the child is left, each time the mother or nurse returns, the crying bursts forth again with renewed force and vigour. It is at least one good plan with a little child to turn the light out, and, treating the whole incident in the most matter-of-fact way possible, lightly to stroke his head or pat his back rhythmically without speaking. With older children, if the crying is more purposeful and less emotional, the mother may busy herself for a little with some task in the room, ostentatiously neglecting the storm and making no reference to it. If she speaks to the child at all she should do so in a matter-of-fact way, referring lightly to other matters. If only she can convince him that his conduct is a matter of indifference to her, the victory is won. It is because the child knows so well that his mother does care that he so often has the upper hand. It is not difficult to distinguish between a true emotional storm and the tyrannous cry of a wilful child who demands his own way.
Light and broken sleep is a common accompaniment of a too excitable and overstimulated brain. The placid child, who eats well, plays quietly, and does not cry more than is usual, as a rule sleeps so soundly that no ordinary sounds, such as conversation carried on in quiet tones in his neighbourhood, have the power to waken him. When he wakes, he does so gradually, perhaps yawning and stretching himself. The nervous child may move at the slightest sound, or with a sudden start or cry is wide awake at once. A hard mattress should be chosen without a bolster, and with only a low pillow. Flannel pyjamas, which cannot be thrown off in the restless movements of the child, should be worn. The temperature of the room should be cool, and the air from the open window should circulate freely, while draughts may be kept from striking on the child by a screen. All the sensations of the nervous child are abnormally acute. Thus, for example, an itching eruption, or tight clothing, will produce an altogether disproportionate reaction, and may result in a frenzy of opposition. Especially such a child is sensitive to a stuffy atmosphere or to an excess of bedclothes. Cool rooms and warm but light and porous clothing are essential. An electric torch, which can be flashed on the child for an instant, will assist the mother or nurse to make sure that the child has not thrown off all the bedclothing.
Sometimes want of sleep is accounted for by a real want of physical exercise. Town children especially are apt to suffer from their limited opportunities of running freely in the open. It is often considered enough that the child seated in his perambulator should take the air for three or four hours daily, while much of his time indoors as well is devoted to sitting. It is necessary for his proper development that he should have opportunities of daily exercise in the open. If for any reason this is not always practicable, a large room, as free as possible from furniture, should be chosen, with windows thrown wide open, in which the child may romp until he is tired.
It is rare for children of two or of three years of age, whose case we are now considering, to be troubled by bad dreams, nightmares, or night-terrors. If these should occur, obstructed breathing due to adenoid vegetations is sometimes at work as a contributory cause.
Finally, we should always remember that refusal of sleep is, for the most part, caused and kept up by harmful suggestions derived from mother and nurse, who allow the child to perceive their distress and agitation, who speak before the child of his habitual wakefulness, who unwittingly focus his attention on the difficulty. It is cured in the moment that the suggestion in the child's mind is reversed, in the moment when he comes to regard it as characteristic of himself not to make a fuss about going to bed, but to sleep with extraordinary readiness and soundness. Let every one join together to produce this effect. Let the suggestion act strongly on his mind that all these troubles of sleeplessness are diminishing, that night after night sees an improvement, and soon his reputation as a good sleeper will be established, and, as always with children, it will be rigidly adhered to.
In assisting to break the habit of sleeplessness, and in the process of altering the character of the suggestions which act on the child's mind, we can be of the greatest assistance to the mother by prescribing a suitable hypnotic. As to whether it is right in insomnia in childhood to prescribe depressant drugs is a question on which very various opinions are held. That it is wrong and probably ineffective to trust entirely to the drugs is certainly true, but as a temporary measure, to break the faulty suggestion and the bad habit, their use is both legitimate and successful. The dose required in children relatively to the adult is much smaller. In grown people, some specific distress of mind, whether real or imaginary, may suffice to resist very large doses of hypnotic. In children it is rare to find the same resistance, and comparatively small doses have a very constant effect. With deeper and more refreshing sleep, the conduct of the child during the day almost always changes for the better. A sound sleep, for a few nights in succession, will produce apparently quite a remarkable change in the whole disposition of the child. When good temper and interest take the place of fretfulness and restlessness, we may confidently expect that the symptom of sleeplessness will begin to abate. Sleeplessness by night and fretfulness by day form a vicious circle, and attempts must be made to break it at all points.
Chloral occupies the first place as a hypnotic for young children. In combination with bromide its effects are wonderfully constant and certain. Two grains of chloral hydrate and two grains of potassium bromide with ten minims of syrup of orange, given just before bedtime, will bring sound sleep to a child of a year old. At three years the dose may be twice as great, and three times at six years. It is seldom that other means are required. Aspirin for children seems relatively without effect. For children who are both sleepless and feverish, a grain of Dover's powder, and a grain of antipyrin, for each year of the child's age up to three, is very helpful. Lastly, if chloral and bromide cannot break the insomnia, and the condition of the child is becoming distressing, we can almost always succeed if we combine the prescription with an ordinary hot pack for twenty minutes.
Habit Spasm
Next to refusal of food and refusal of sleep perhaps the most frequent manifestation of nervous unrest is provided by the group of symptoms which we may call, with a certain latitude of expression, Habit Spasms. By a habit spasm is meant the constant repetition of an action which was originally designed to produce some one definite result, but which has become involuntary, habitual, and separated from its original meaning. The nervous cough forms a good example of a habit spasm. A cough may lose its purpose and persist only as a bad habit, especially in moments of nervousness, as in talking to strangers, in entering a room, or at the moment of saying "How do you do" or "Good-bye." Twitching the mouth, swallowing, elongating the upper lip, biting the lips, wrinkling the forehead so strongly that the whole scalp may be put into movement, and blepharospasm are all common tricks of little children which may become habitual and uncontrolled. In worse cases there may be constant jerking movements of the head, nodding movements, or even bowing salaam-like movements. In mild cases we may note hardly more than a restless movement of mouth or forehead, or constant plucking or writhing of the fingers whenever the child's attention is aroused, when he is spoken to, or when he himself speaks. In nervous children these movements, which should properly be confined to moments of real emotional stress, become habitual, and are displayed apart from the excitement of particular emotions. Whatever their intensity, habitual and involuntary movements of this nature should not be overlooked, and should be regarded as evidence of mental unrest. They do not commonly appear during the first or second years of the child's life. They are more frequent after the age of five, but they may begin to be marked as early as the third year. With refusal of food and refusal of sleep they form the three common neuroses of early childhood.
Two of the three qualities which we have mentioned as characteristic of the child's mind are concerned in the causation of habit spasm. In the early stages the movement is sometimes due to imitation, but the susceptibility of the child to suggestion plays the chief part in determining its persistence. It is an interesting speculation how far tricks of gesture, attitude, or gait are inherited and how far they are acquired by imitation. A child by some characteristic gesture may strikingly call to mind a parent who died in his infancy. A whole family may show a peculiarity of gait which is at once recognisable. It is told of the son of a famous man, who shared with his father the distinctive family gait, that when a boy his ears were once boxed by an old gentleman who chanced to observe him hurrying to overtake his parent, and who resented what he took to be an act of impertinent caricature. In the reproduction by the child of the habitual actions of his parents, heredity is largely concerned, but imitation too plays its part. In habit spasm the force of imitation is clearly seen. A child who has developed a habit spasm of one sort or another will readily serve as a model to other children. The malady will sometimes spread through a school almost with the force of a contagious disorder. A child affected in this way may prove an unwelcome guest. The little visitor with a trick of contorting his mouth and grimacing is apt to leave his small host an expert in faithfully reproducing the action. A cough that is genuine enough in one member of the family may produce a crop of counterfeits in brothers and sisters.
The force of suggestion acting upon the child's mind can clearly be traced. Once his attention is focused upon the particular movement by unwise emphasis on the part of the parents, he loses the power to control its occurrence. This trio of common neuroses—refusal of food, refusal of sleep, and habitual involuntary movement—grows only in an atmosphere of unrest and apprehension. Parents and nurses anxiously watch their development. They are distressed beyond measure to note their steady growth in spite of every attempt which they make to control or forbid them. And of all this unrest and unhappiness the child is acutely conscious. The whole household may become obsessed with the misfortune which has befallen it, and the mother, losing all sense of proportion, feels that she cannot regain her peace of mind until it has been overcome. The child is in need of mental and moral support from those around him, and all that he finds is an openly expressed apprehension and sense of impotence. Even grown-up people, when their nerves are on edge, are apt to be obsessed by uncontrollable impulses or by vague and nameless apprehensions, and surely all have learnt the support they gain from contact and conversation with some one strong and sane, who treats their worries in such a matter-of-fact way that immediately they lose their power and become of no account. The child with habit spasm cannot control these movements. The more he is reproved or entreated, the less able does he find himself to hold them in check. He does not wish them to continue. He has lost control of what he once controlled, and the realisation of this is not pleasant, and may be alarming to him. Yet when unconsciously he looks to his mother for support, he finds in her open dismay that which serves only to increase his uneasiness. She must subdue her own feelings and give the child strength. If she treats the whole thing in a matter-of-fact way, as a temporary disturbance which is of no importance in itself, and only has meaning because it implies that the brain has been over-stimulated, she will no longer exercise a prejudicial effect on the child. If the bad habit is taken as a matter of course, if too much is not made of it, if the child is encouraged to think that nobody cares much about it at all, then recovery will soon take place. It goes without saying that habit spasms and tics of all sorts are made worse by excessive emotional display and by nervous fatigue. On the other hand, if the child becomes absorbed in some interesting occupation, the movements will disappear for the time being.
Air Swallowing, Thigh Rubbing, Thumb Sucking
At a somewhat earlier age than that in which habit spasms become common, and before bed wetting appears as a formidable difficulty, we meet with another group of habitual actions which yet retain their voluntary character. Among such habitual actions are thumb sucking, thigh rubbing, and air swallowing. If the child is old enough to express himself on the subject, he will explain that these actions are performed because of the satisfaction derived from them, because it is "comfy" and "nice." Even if the child is too small to speak, the expression is that of beatitude and content. These actions are not confined to nervous children, and their occasional practice need not be taken to imply that there is any strong element of nervous overstrain. It is only when the action is repeated with great frequency and persistence, and when signs of irritation ensue if gratification is not obtained, that we are justified in classing it among the symptoms of mental unrest.
The second of these actions, thigh rubbing, is found for the most part in little girls, and inasmuch as it consists of a stimulation of the sexual organs sometimes causes much distress to the parents. It is in reality a habit of small importance unless exercised with very great frequency. It is, of course, not associated in the child's mind with any sexual ideas, and is of precisely the same significance as the other two actions of the same class. Children who can speak will refer to it openly without any sense of shame. As a rule the action is performed in a half-dream state, that condition between sleeping and waking which is found when the child is lying in the morning in her cot or in her perambulator after the midday nap. The child's attention should not be focused on the symptom. She should lie on a hard mattress, and when she wakes in the morning she should either leave her cot at once or she should be roused into complete wakefulness by encouraging her to play with her toys. Little children should be taught to sleep with their hands folded and placed beside the cheek. If the movement occurs on going to sleep, it is best left alone and completely neglected. As a rule each child has his or her own favourite action of this class, and they are seldom combined in the same child. If thigh rubbing is very constant and obstinate and does not yield to the measures suggested, it may even sometimes be a successful manoeuvre to substitute the thumb-sucking habit in the expectation that this less distressing habit may eject the other more objectionable action. As a rule, however, a wise neglect and careful watching during the drowsy condition that follows sleep in a warm bed will succeed in stopping the practice of thigh rubbing before the end of the second or third year. Apparatus designed to restrain movement of the child's legs or blistering the opposed surfaces of the thighs are both of no effect. They have indeed the positive disadvantage that they focus the child's attention on the practice. The habit ceases only when the child has forgotten all about it, and these devices serve only to keep it in remembrance. The same may be said of any system of punishments. Further, we cannot always have the child under observation, and at some time or other opportunity will be found for gratification. Of older children, in whom self-control and a sense of honour can be cultivated, I am not here speaking.
Air swallowing is less common than thigh rubbing, but belongs to the same group of actions and takes place in the same drowsy condition. The child will rapidly gulp down air which distends the stomach, and is then regurgitated with a loud sound. Thumb sucking seldom distresses the mother to the same extent, and the proper attitude of tolerance is adopted towards it. If much is made of it, it is astonishing how persistent the habit may become, surviving all attempts to forbid it, to break it by rewards or punishments, or to render it distasteful by the application of a variety of ill-tasting substances smeared on the offending digit.
Pica and Dirt Eating
Certain other bad habits will become ingrained if attention is called to them, because of that curious spirit of opposition which characterises little children, and because of their susceptibility to suggestion. Some children will constantly pluck out hairs and eat them, or will devour particles of fluff drawn from the blankets. Others will seize every opportunity to eat unpleasant things, such as earth, sand, mud, or dirt of any sort. All tricks of this sort are best neglected and treated by attracting the child's attention to other things. In adult life they are associated with serious mental disturbance, in early childhood they are of little account, or at most suggest a certain nervousness which may be due to nervous irritation from faults of management which we must strive to correct.
Constipation
As has been already mentioned, much of the common constipation of the nursery is due to neurosis. The excessive concentration of the nurse's thoughts on this daily question communicates itself to the child. The difficulty is emphasised, and an attempt is made to substitute will power for forces of suggestion which are at once inhibited by concentration of the mind upon the process. Here also, just as in the refusal of food, a further stage of "negativism," that is, of active resistance with crying and struggling, is reached, so that complaint may be made by the mother that defæcation is painful. The same negativism may be shown in micturition, and mothers will give distressing accounts of the suffering of the child during the passing of water.
Breath-Holding and Laryngismus Stridulus
In some children, in the first two years of life, we find a definite and measurable increase in the irritability and conductivity of the peripheral nerves. The strength of current necessary to produce by direct stimulation of the nerve a minimal twitch of the corresponding muscle may be many times less than the normal. Of this heightened irritability of the nervous system, to which the name "spasmophilia" has been given in America and on the Continent, the most striking symptom is a liability alike to tetany or carpo-pedal spasm, to generalised convulsions, and to laryngismus stridulus. In addition, in most cases it is generally possible to demonstrate the presence of Chvostek's sign and of Trousseau's sign. Chvostek's sign consists in a visible twitch of the facial musculature, especially of the orbicularis palpebrarum or of the orbicularis oris, in response to a gentle tap administered over the facial nerve in front of the ear. Trousseau's sign is the production of tetany by applying firm and prolonged pressure to the brachial nerve in the upper arm. The ætiology of spasmophilia is still a matter for dispute, but the evidence which we possess is in favour of the view that we have here to deal with a disturbance of calcium metabolism. The calcium content both of the blood and of the central nervous system has been shown to be much lowered. It is in keeping with this that clinically we note how frequently spasmophilia and rickets occur in the same child. In some families the condition recurs through many generations.