The grown-up person comes eventually to be able to control this tremendous organ, this brain, which is the predominant feature of his race. In the child its functions are always unstable and liable to be upset. Evidence of mental unrest or fatigue, which is only rarely met with in grown persons and which then betokens serious disturbance of the mind, is of comparatively common occurrence in little children. Habit spasm, bed-wetting, sleep-walking, night terrors, and convulsions are symptoms which are frequent enough in children, and there is no need to be unduly alarmed at their occurrence. In adult age they are found only among persons who must be considered as neuropathic. To make the point clear, I have chosen examples from the graver and more serious symptoms of nervous unrest. But it is equally true that minor symptoms which in adults are universally recognised to be dependent upon cerebral unrest or fatigue are of everyday occurrence in childhood. Broken and disturbed sleep, absence of appetite and persistent refusal of food, gastric pain and discomfort after meals, nervous vomiting, morbid flushing and blushing, headache, irritability and excessive emotional display, at whatever age they occur, are indications of a mind that is not at rest. In children, as in adults, they may be prominent although the physical surroundings of the patient may be all that could be desired and all that wealth can procure. It is an everyday experience that business worries and responsibilities in men, domestic anxieties or childlessness in women, have the power to ruin health, even in those who habitually or grossly break none of its laws. The unstable mind of the child is so sensitive that cerebral fatigue and irritability are produced by causes which seem to us extraordinarily trivial. In the little life which the child leads, a life in which the whole seems to us to be comprised in dressing and undressing, washing, walking, eating, sleeping, and playing, it is not easy to detect where the elements of nervous overstrain lie. Nor is it as a rule in these things that the mischief is to be found. It is in the personality of mother or nurse, in her conduct to the child, in her actions and words, in the tone of her voice when she addresses him, even in the thoughts which pass through her mind and which show themselves plainly to that marvellously acute intuition of his, which divines what she has not spoken, that we must seek for the disturbing element. The mental environment of the child is created by the mother or the nurse. That is her responsibility and her opportunity. The conduct of the child must be the criterion of her success. If things go wrong, if there is constant crying or ungovernable temper, if sleep and food are persistently refused, or if there is undue timidity and tearfulness, there is danger that seeds may be sown from which nervous disorders will spring in the future.
There are many women who, without any deep thought on the matter, have the inborn knack of managing children, who seem to understand them, and have a feeling for them. With them, we say, the children are always good, and they are good because the element of nervous overstrain has not arisen. There are other women, often very fond of children, who are conspicuously lacking in this power. Contact with one of these well-meaning persons, even for a few days, will demoralise a whole nursery. Tempers grow wild and unruly, sleep disappears, fretfulness and irritability take its place. Yet of most mothers it is probably true that they are neither strikingly proficient nor utterly deficient in the power of managing children. If they lack the gift that comes naturally to some women, they learn from experience and grow instinctively to feel when they have made a false step with the child. Although by dearly bought experience they learn wisdom in the management of their children, they nevertheless may not study the subject with the same care which they devote to matters of diet and hygiene. It is the mother whose education and understanding best fits her for this task. In this country a separate nursery and a separate nursery life for the children is found in nearly all households among the well-to-do, and the care for the physical needs of the children is largely taken off the mothers' shoulders by nurses and nursemaids. That this arrangement is advantageous on the whole cannot be doubted. In America and on the Continent, where the children often mingle all day in the general life of the household, and occupy the ordinary living rooms, experience shows that nerve strain and its attendant evils are more common than with us. Nevertheless, the arrangement of a separate nursery has its disadvantages. Nurses are sometimes not sufficiently educated to have much appreciation of the mental processes of the child. If the children are restless and nervous they are content to attribute this to naughtiness or to constipation, or to some other physical ailment. Their time is usually so fully occupied that they cannot be expected to be very zealous in reading books on the management of children. Nevertheless, in practical matters of detail a good nurse will learn rapidly from a mother who has given some attention to the subject, and who is able to give explicit instructions upon definite points.
It is right that mothers should appreciate the important part which the environment plays in all the mental processes of children, and in their physical condition as well; that they should understand that good temper and happiness mean a proper environment, and that constant crying and fretfulness, broken sleep, refusal of food, vomiting, undue thinness, and extreme timidity often indicate that something in this direction is at fault.
Nevertheless, we must be careful not to overstate our case. We must remember how great is the diversity of temperament in children—a diversity which is produced purely by hereditary factors. The task of all mothers is by no means of equal difficulty. There are children in whom quite gross faults in training produce but little permanent damage; there are others of so sensitive a nervous organisation that their environment requires the most delicate adjustment, and when matters have gone wrong, it may be very difficult to restore health of mind and body. When a peculiarly nervous temperament is inherited, wisdom in the management of the child is essential, and may sometimes achieve the happiest results. Heredity is so powerful a factor in the development of the nervous organisation of the child that, realising its importance, we should be sparing in our criticism of the results which the mothers who consult us achieve in the training of their children. A sensitive, nervous organisation is often the mark of intellectual possibilities above the average, and the children who are cast outside the ordinary mould, who are the most wayward, the most intractable, who react to trifling faults of management with the most striking symptoms of disturbance, are often those with the greatest potentialities for achievement and for good. It is natural for the mother of placid, contented, and perhaps rather unenterprising children, looking on as a detached outsider, seeing nothing of the teeming activities of the quick, restless little brain, and the persistent, though faulty reasoning—it is natural for her to blame another's work, and to flatter herself that her own routine would have avoided all these troublesome complications. The mother of the nervous child may often rightly take comfort in the thought that her child is worth the extra trouble and the extra care which he demands, because he is sent into the world with mechanism which, just because it is more powerful than the common run, is more difficult to master and takes longer to control and to apply for useful ends.
It is through the mother, and by means of her alone, that the doctor can influence the conduct of the child. Without her co-operation, or if she fails to appreciate the whole situation, with the best will in the world, we are powerless to help. Fortunately with the majority of educated mothers there is no difficulty. Their powers of observation in all matters concerning their children are usually very great. It is their interpretation of what they have observed that is often faulty. Thus, in the example given above, the mother observes correctly that defæcation is inhibited, and produces crying and resistance. It is her interpretation that the cause is to be found in pain that is at fault. Again, a mother may bring her infant for tongue-tie. She has observed correctly that the child is unable to sustain the suction necessary for efficient lactation, and has hit upon this fanciful and traditional explanation. The doctor, who knows that the tongue takes no part in the act of sucking, will probably be able to demonstrate that the failure to suck is due to nasal obstruction, and that the child is forced to let go the nipple because respiration is impeded. The opportunities for close observation of the child which mothers enjoy are so great that we shall not often be justified in disregarding their statements. But if we are able to give the true explanation of the symptoms, it will seldom happen that the mother will fail to be convinced, because the explanation, if true, will fit accurately with all that has been observed. Thus the mother of the child in whom defæcation is inhibited by negativism may have made further observations. For example, she may have noted that the so-called constipation causes fretfulness, that it is almost always benefited by a visit to the country or seaside, or that it has become much worse since a new nurse, who is much distressed by it, has taken over the management of the child. To this mother the explanation must be extended to fit these observations, of the accuracy of which there need be no doubt. Fretfulness and negativism with all children whose management is at fault come in waves and cycles. The child, naughty and almost unmanageable one week, may behave as a model of propriety the next. The negativism and refusal to go to stool are the outcome of the nervous unrest, not its cause. Again, the nervous child, like the adult neuropath, very often improves for the time being with every change of scene and surroundings. It is the ennui and monotony of daily existence, in contact with the same restricted circle, that becomes insupportable and brings into prominence the lack of moral discipline, the fretfulness, and spirit of opposition. Lastly, the conduct of the nervous child is determined to a great extent by suggestions derived from the grown-up people around him. Refusal of food, refusal of sleep, refusal to go to stool, as we shall see later, only become frequent or habitual when the child's conduct visibly distresses the nurse or mother, and when the child fully appreciates the stir which he is creating. The mother will readily understand that in such a case, where constipation varies in degree according as different persons take charge of the child, the explanation offered is that which alone fits with the observed facts. A full and free discussion between mother and doctor, repeated it may be more than once, may be necessary before the truth is arrived at, and a line of action decided upon. Only so can the doctor, remote as he is from the environment of the child, intervene to mould its nature and shape its conduct.
If the doctor is to fit himself to give advice of this sort, he must be a close observer of little children. He must not consider it beneath his dignity to study nursery life and nursery ways. There he will find the very beginnings of things, the growing point, as it were, of all neuropathy. A man of fifty, who in many other ways showed evidence of a highly nervous temperament, had especially one well-marked phobia, the fear of falling downstairs. It had never been absent all his life, and he had grown used to making the descent of the stairs clinging firmly to the stair-rail. Family tradition assigned this infirmity to a fall downstairs in early childhood. But all children fall downstairs and are none the worse. The persistence of the fear was due, I make no doubt, to the attitude of the parents or nurse, who made much of the accident, impressed the occasion strongly on the child's memory, and surrounded him thereafter with precautions which sapped his confidence and fanned his fears.
In what follows we will consider first the subject of nursery management, searching in it for the origin of the common disorders of conduct both of childhood and of later life. I have grouped these nursery observations under the heads of four characteristic features of the child's psychology—his Imitativeness, his Suggestibility, his Love of Power, and his acute though limited Reasoning Faculties. I feel that some such brief examination is necessary if we are to understand correctly the ætiology of some of the most troublesome disorders of childhood, such as enuresis, anorexia, dyspepsia, or constipation, disorders in which the nervous element is perhaps to-day not sufficiently emphasised. Finally, we can evolve a kind of nursery psycho-therapeutics—a subject which is not only of fascinating interest in itself, but which repays consideration by the success which it brings to our efforts to cure and control.